Handbook for Healthy Kids Services Chapter HK-200 ... - HFS

Handbook for Providers of Healthy Kids Services Chapter HK-200 – Appendices 

Appendix 1 

Anticipatory Guidance 

Note: All of the below topics may not be appropriate for each family. The provider 

should make a decision based on assessment of needs and observations. However, 

HFS’ recommendations for minimal area(s) to be addressed are included in the text to 

follow. There are some areas that should be assessed initially and then visited only 

periodically or if the family has moved or otherwise changed. 

Newborn: 

� Importance of Healthy Kids (EPSDT) visits and immunizations and developmental 

screening 

� Signs and symptoms of illness, e.g., neonatal jaundice; instruct when and how to 

contact doctor 

� Review the results of the newborn hearing screen with parent/guardian; make 

referrals, as necessary 

� Common questions and concerns of parents 

� Sleep position based on current standards of practice 

� Co-sleeping current standard of practice 

� Diapering, rashes and infant hygiene including circumcision and umbilical care 

� Thermometer use, temperature ranges that need to be called to doctor 

� Importance of car safety restraints, e.g., placing child in back seat of car facing 

backward 

� Home safety and injury prevention, e.g. crib safety; bath temperature; smoke 

detectors; carbon monoxide detectors; microwave/bottle temperature, and gun 

safety, if applicable 

� Gratification of infant’s need for contact, e.g., holding, rocking, interacting 

� Recognizing infant states 

� Ways to calm a crying infant, e.g., quiet infant with paroxysmal fussiness or colic 

� Infant individuality, e.g., differences in infant temperament 

� Prepare for possible sibling reactions 

� Recognizing signs infant is hungry 

� Breast-feeding or bottle-feeding; stress benefits and resources for breast-feeding 

support, as appropriate 

� Good parenting practices; availability of parenting classes and how to deal with 

unwanted advice 

� Postpartum adjustment; discuss range of postpartum difficulties including “blues” 

and depression 

� Family planning needs of mother 

� Risks of parental tobacco, alcohol and drug use to infant 

� Shaken Baby Syndrome 

� Emergency Procedures 

� Available resources, e.g., WIC; Family Case Management; Early Intervention 

� Sun exposure 

� How their infant is developing 

� How they are doing as parents 

March 2008 HFS Appendix HK-1 (1)


2 - 4 Weeks: 

� Importance of next EPSDT visit, including immunizations 

� Review the results of the newborn hearing screen with parent/guardian; make 

referrals, as necessary 

� When and how to call doctor - recognizing early signs of illness 

� Injury prevention for age, e.g., never leave baby alone in tub of water, high places or 

with siblings; proper infant restraint/car seat use; sun exposure; setting hot water 

thermostat lower than 120 °F 

� Crib safety 

� Diapering, rashes and infant hygiene 

� Sleep patterns and positions 

� Bladder and bowel habits 

� Infant development and milestones 

� Encourage infection prevention 

� Guidance about crying 

� Gratification of infant’s basic needs 

� Types of infant stimulation and its importance 

� Development of baby’s cognitive abilities 

� Child care providers, e.g., what to look for in “good” child care 

� Nutrition and fluoride needs 

� Discuss breastfeeding support, as appropriate 

� Burping techniques and spitting up 

� Encourage parents to spend time together 


� Parental tobacco, alcohol and drug use - risks to infant 

� Infant cardiopulmonary resuscitation (Infant CPR) 

� Choking prevention and first aid 


� Emergency Procedures 

� Available resources, e.g., WIC; Family Case Management; Emergency Resources; 

Early Intervention 

� Returning to work 

� Signs of postpartum depression 



2 months: 


� Injury prevention, e.g., never leave baby alone with young siblings; proper infant 

restraint/ car seat use; sun exposure; 


� Sleep patterns and positions 

� Early signs of illness 

� Outline what to do in an emergency 

� Developmental issues and milestones 

� Age-appropriate stimulation 

� Age-appropriate toys 

� Importance of infant-parent interaction 

� Playing with toys, parents, siblings, others 

� Childcare issues 




� Feeding instructions, e.g., delaying solids 

� Family relationships 



� Available resources, e.g., WIC; Family Case Management; Emergency Resources; 

Early Intervention 

� Signs of Postpartum Depression 



4 months: 


� Injury prevention for age, e.g., infant rolling and falling; bath and bottle temperature; 

never leave baby alone with young siblings; proper infant restraint/car seat use; sun 

exposure 


� Sleep position 

� Promoting healthy sleep habits, bedtime routines 

� Development issues and milestones 

� Discuss “spoiling” 

� Good and appropriate childcare 

� Emphasize family strengths 

� Good parenting practices, e.g., holding and rocking infant; responding to infant; 

reading to infant; providing same transitional object at bedtime or in new situation to 

teach self-consoling behavior 


� Nutrition and oral hygiene; early childhood carries 

� Teething 

� Introduction of solid food when developmentally ready 



� Maintaining religious, cultural, recreational, and social community ties 


� Available resources, e.g., WIC; Family Case Management; Early Intervention 

� TV time 

� Important baby routines and infant temperament 

� Baby walkers 



6 months: 


� Injury Prevention for age, e.g., never leave baby alone with young siblings; proper 

infant restraint/car seat use; limit sun exposure; avoid giving baby food that may be 

inhaled or may cause choking; keep number of local poison control near telephone 

� Toy safety 


� Sleep patterns and position 

� Need for shoes 



� Discuss care of URI’s, diarrhea, dehydration, and irritability 

� Developmental issues and milestones, refer as necessary 

� Need for answering all cries within a reasonable amount of time 

� Stranger anxiety 

� Age-appropriate stimulation, e.g., encouraging play with age appropriate toys 

� Discuss parent-child relationships, e.g., reading to baby; social games and 

exploration 


� Nutrition and early childhood carries 

� Teething/drooling/oral hygiene 

� Good parenting practices, e.g., need for consistency and age appropriate discipline 



� Available resources, e.g., WIC; Family Case Management; Early Intervention; 

Emergency Resources 

� TV time 

� Introducing solid foods 

� Family meals 

� Basic Discipline 



9 months: 


� Injury prevention, e.g., car safety; poisons; sun exposure; use of infant safety gate; 

upgrading to a toddler car restraint seat when the infant weighs 20 pounds 

� Child Safety, e.g., lowering mattress in baby’s crib; emptying buckets, tubs or small 

pools immediately after use 

� Home safety, fire and burn prevention 

� Discuss learning infant/child CPR 


� Sleep practices 

� Shoe types and fit 

� Developmental issues and milestones 

� Signs and symptoms of illness 

� Separation protests/stranger anxiety 

� Childcare providers/issues 


� Nutrition and oral hygiene, e.g., table foods; family meals; open vs. sippy cup; early 

childhood caries; encourage baby to feed self as much as possible 

� Good parenting practices, e.g., setting routines 

� Emphasize family strengths, explore range of parental supports 



� Available resources, e.g., WIC; Family Case Management; Early Intervention; 

Emergency Resources 

� TV time 

� Reading to baby daily 

� Readiness for weaning 

� Separation anxiety 



� Limit setting 

� How their baby is developing 


12 months: 


� Diapering, rashes, infant hygiene, delaying toilet training 

� Accident prevention, e.g., child proofing home; climbing; car seat use; sun exposure; 

safety gates; safety plugs; firearm safety 

� Child Safety e.g., confining toddler’s outside play to areas within fences and gates; 

turning panhandles toward back of stove; keeping toddler away from stoves, 

fireplaces, irons, curling irons and space heaters; checking home for lead poisoning 

hazards; keeping toddler away from lawn mower and other moving machineries 

� Bedtime ritual 

� Developmental milestones, refer as necessary 

� Signs of illness and what to do in emergency situation 

� Speech development 

� Age appropriate stimulation, e.g., reading to child daily; playing games; singing and 

talking 

� Child’s need for autonomy and expression of curiosity 

� Handling the “Nos” of being a toddler 

� Temper tantrums 

� Childcare and caregiver issues 

� Consistency in discipline, e.g., use of praise and reassurance 


� Nutrition, e.g., table foods; plans to discontinue bottle feeding; choking hazards; 

anticipate decrease in appetite 

� Dental hygiene and early childhood caries; visit to dentist and fluoride as necessary 

� Emphasize family strengths, explore range of parental supports 

� Family planning needs of mother and spacing of children 

� Risks of parental tobacco, alcohol and drug use to risks to child 

� Available resource, e.g., WIC; Early Intervention; Emergency Resources 

� TV and computer time 

� Fears in early childhood 



15 months: 

� Importance of next EPSDT visit 

� Injury prevention, e.g., poisons; falls; stoves; electrical outlets; car seat use; sun 

exposure/sunscreen; safety gates; safety plugs; firearm safety 

� Child Safety, e.g., keeping cigarettes, lighters, matches and alcohol out of toddler’s 

sight and reach; wearing helmet when riding on a seat on adult’s bicycle 

� Water safety 

� Sleep practices; regular bedtime routines; sleep resistance 

� Early morning riser 

� Night awakening; nighttime feeder; crier 

� Toilet training readiness 

� Developmental milestones 

� Child’s language 



� Developmental issues, e.g., curiosity; interest in peers; intellectual development 

� Separation protest 

� Bedtime fears 

� Transitional objects 

� Moving from a crib to a big bed 

� Discipline, limit setting and the use of positive reinforcement; discipline as a means 

of teaching and protecting-not punishing; develop strategies to manage power 

struggle resulting from toddler’s need to control environment 

� Handling behavior problems in public places 


� Choosing and evaluating day care options 

� Nutrition and oral hygiene; early childhood caries; fluoride; appropriate snacks; selffeeding 

� Good parenting practices, e.g., talking, singing and reading with toddler; appropriate 

television watching 

� Emphasize family strengths; explore range of parental supports 

� Family planning for teenage parents 

� Risk of parental or caregiver’s use of tobacco, alcohol and drugs to child 

� Available resources, e.g., WIC; Early Intervention; Emergency Resources 

� Oral hygiene 




18 months: 

� Importance of next EPSDT visit, immunizations 

� Injury prevention, e.g., firearm safety; balloons; plastic bags; car seat use; 

safety gates; safety plugs 


� Sleep practices, discuss night fears 


� Development issues and milestones 

� Discipline - positive reinforcement and praise 

� Self-comforting behaviors 


� Choosing and evaluating day care or preschool 

� Nutrition, e.g., choking hazards 

� Oral care, e.g., early childhood caries; fluoride; brushing teeth 


� Good parenting practice, e.g. limiting child use of TV time; encouraging family 

communication; modeling appropriate language; promoting a sense of competence 

and control by encouraging toddler to make choices whenever possible 

� Reading to child daily 

� Language 

� Fear of strangers 

� Limit setting 

� Adjusting to a new baby; sibling rivalry 

� Parental educational opportunities, e.g., participating in parent-toddler play group 

� Risks of parental/caregiver’s use of tobacco, alcohol and drugs to child 

� Available resource, e.g., WIC; Early Intervention; Emergency Resources 






24 months: 

� Importance of EPSDT visits and follow-up visits if needed 

� Injury prevention, e.g., streets; falls; matches; guns; knives; keeping hot liquids out 

of reach; car seat use; safety gates; safety plugs 



� Sleep issues, e.g., night fears and nightmares 

� Developmental issues; autonomy; dependency and conflict 

� Normal body curiosity 

� Mild speech dysfluency 

� Childcare providers 

� Age appropriate stimulation; reading; telling stories; pretend activity; television 

supervision and limits; singing; parallel play; self-expression 

� Using time out appropriately 

� Help child express feelings like joy, anger, sorrow, fear and frustration 

� Nutrition, e.g., family meals; snacks 

� Dental care, e.g., dental visit every 6 months 

� If mother is pregnant, talk about the impact of pregnancy on a two-year-old 


� Good parenting practices, e.g., reading to child daily; singing; allowing parallel play 

with other children 

� Risks of parental/caregiver’s use of tobacco, alcohol, and drugs to child 

� Available resources, e.g., WIC; Early Intervention; Emergency Resources 

� Conduct fire drills at home 

� TV, computer time and family time 

� How their toddler is developing 


3 years: 

� Importance of EPSDT visits and any follow-up 

� Injury prevention, e.g., appropriate car seat; water supervision; sunscreen; hot 

liquids; matches 

� Toilet training, e.g., lapses in control, especially at night 

� Developmental issues, e.g., sexual curiosity; onset of fears; rivalry 

� Interest in language; encourage discussion of activities with child 

� Discipline 

� Nursery school/day care 

� Hurting another child 

� Handling anger 

� Nutrition, e.g., three meals/day; avoid small hard food; healthy snacks 

� Anticipate child’s normal curiosity about genital differences in boys and girls 

� Introduce notion that all parts of the body are not to be touched without permission 

� Dental care; dental visit every 6 months 


� Teach about “stranger danger” 

� Importance of routines 



� Child pedestrian safety skills 

� Risks of parental/caregiver’s use of tobacco, alcohol and drugs to child 

� Available resources, e.g., WIC; Emergency Resources; Preschool programs 

including referral of children with special health care needs to the school district 

� Preschool readiness 

� Making friends 

� Sibling rivalry 


� How their preschooler is developing 


4 - 5 year olds: 

� Importance of EPSDT visits and immunizations 

� Teach child how to swim 

� Safety, e.g., guns; playground; neighborhood and water safety; strangers 

� Allow child to cultivate problem solving attitude 

� Do not allow violent behavior 

� Encourage assertiveness without aggression 

� Toilet training and night accidents 

� Age appropriate sex education 

� Discipline; limit setting 

� Teach child all emergency numbers 

� Developmental issues 

� Environmental Stimulation, e.g., nursery school; increased excursions (zoos, 

museums, fire and police stations, amusement parks 

� Building self confidence 

� Assign age appropriate chores 

� Nutrition, e.g., meals; nutritious foods; snacks 

� Dental care and dental emergencies; dental visit every 6 months 

� Limit and supervise television watching 

� TV violence and computer time 


� Encourage development of good sibling relationships 

� Available resources, e.g., WIC; Preschool programs including referral of children 

with special needs to the school district 

� Home playground 

� School readiness 

� How their preschooler is developing 


SCHOOL AGED CHILDREN 

� Safety: bicycles; seat belts; matches; fires; poison; water safety; skateboards; 

playing in the street; awareness of strangers; how to find help; sunscreen; staying 

smoke/drug free; guns; peer pressure; sport safety; supervision after school 

� Developmental needs: 

o Talking out problems with family members by expressing thoughts and feelings 

o Child needs secure home environment to develop a sense of belonging 

o Needs parent reinforcement to develop self-confidence 

o Needs freedom to explore new skill areas 



o Recognize children’s need for approval of others to develop personal 

assessment of how they fit into their world 

o Friends are important 

o Develop sense of right and wrong; set consistent limits that are reasonable; 

provide healthy role models; punishment/discipline that fits the wrong-doing 

(reassuring of parental love following correction; anger/conflict and resolution; 

authority respect 

� Fostering interest in school, e.g., peer interaction; peer pressure; foster reading; 

team play; group activities 


� How their child is developing 


6 years: 

� Importance of EPSDT visits 

� Good health habits and self-care 

� Developmental issues 

� Social interaction; encourage parents to know child’s friends 

� Dental care and sealants; dental visit every 6 months 

� Good parenting practices, e.g., discipline; promote responsibility; discuss peer 

pressure and appropriate decision-making skills; self-respect and respect for 

authority 

� Provide personal space for child at home 

� Communicating with child 

� Bullying is not okay 


� Problem solving strategies 

� Teach child about sports and protective gear; bicycle safety; correct size helmets 



8 years: 


� Good health habits; self-care and personal hygiene 

� Prepare girls for menstruation 

� Teach the child how to handle dental emergencies 

� Dental care, e.g., brushing; sealant and daily flossing; dental visit every 6 months 

� Family/social interactions, e.g., community programs; scouts; sports; praise success 

� Promote school/teacher interaction 

� Know child’s friends; teach child not to smoke, use drugs or alcohol 


pressure and appropriate decision-making skills; self respect and respect for 

authority 

� Do not allow child to use power tools 


� Listening strategies for diffusing anger 

� Bullying is not okay 





10 years: 



� Teach child to avoid high noise levels especially using ear phones 

� Danger of drugs; smoking; alcohol and guns 

� Protection from abuse 

� Explore child’s understanding on HIV/AIDS and hepatitis diseases 

� Sex education, e.g., preparation for menstruation; wet dreams and abstinence 

� Encourage parents to know friends and social activities 

� Give child space to do homework 

� Road safety rules for biking and in-line skating 

� Educational activities 


pressure; appropriate decision-making skills; conflict management skills 

� Internet and the family 

� Dangers of alcohol; drugs; inhalant use 



12 years: 


� Good health and self-care including oral care 

� Sex education; body changes; discuss abstinence 

� Protection from abuse 

� Encourage social interaction; religious and spiritual needs 

� Importance of academic activities 

� Importance of parental communications 

� Making wise and healthy choices, e.g., peer pressure; drugs; alcohol; steroids; diet 

pills; sexual activity 

� Importance of a healthy diet and healthy snacks, including fruits and vegetables 

� Educate child not to carry any weapons 

� Good parenting practices, e.g., discipline; promote responsibility; decision-making 

skills; conflict management skills 

� How their pre-teenager is developing 

� How they are doing as parents, including spending time with their pre-adolescent 

ADOLESCENT 

� Nutrition: 

o Needed for growth; hormonal changes; stress; pregnancy; healthy diet practices 

including intake of calcium and folic acid; fruits and vegetables; discussion of 

eating disorders 

� Safety 

o Aggressive behavior; safe driving, seatbelts and helmets; drinking and driving; 

firearms; crime/victim prevention 

� Behavior: 

o Alcohol and substance abuse prevention; marijuana; cocaine; steroids; 

avoidance of smoking or smokeless tobacco use; risk taking; self esteem and 

respect; sexual behavior; TV watching; social actions; sports; study habits; 

making wise choices; positive self-image; teens and depression; 



teen suicide and guns; homework tips; acne treatment; eating disorders; 

handling the anxious child; teen dating and violence 

� Development: 

o Establish identity and body image; ability to think abstractly; increased peer 

interaction/wise choices; increased emancipation from family, e.g., challenges to 

parental authority; onset of idealistic/altruistic thoughts; career goals; 

relationships and sexuality 

� Advise/Counseling: 

o Major events of puberty (including need for testicular self exam, breast self exam 

and information on menstruation); success in school; school activities; family 

relationships; peer relationships; outside interests; attitudes and religious beliefs; 

contraception/abstinence; conflict resolution; unhealthy habits; community 

service and employment; medical, dental and behavioral health resources; HIV 

and AIDS 

o How their teenager is developing 

o How they are doing as parents 

o Spending time with their child/adolescent 

14 years: 

� Safety issues, e.g., seat belts/helmets; mouth guards; body piercing; weapons 

� Take on new challenges in life that will increase confidence 

� Good health habits and self care, e.g., eating habits; healthy diet including healthy 

snacks, such as fruits and vegetables; exercise; injury prevention and substance 

abuse 

� Sexual activity, e.g., STI/HIV transmission; abstinence; sexual orientation; 

contraception 

� Protection from physical, emotional, sexual abuse; date rape 

� Social interaction, e.g., community services; team sports 

� Importance of educational activities 

� Making healthy choices; peer pressure; positive goal setting, e.g., plans for the 

future 

� How their teenager is developing 

� How they are doing as parents, including spending time with their adolescent 

16 years: 

� Good health habits and self-care, e.g., eating habits; healthy diet, including healthy 

snacks, such as fruits and vegetables; sleeping habits; exercise; injury prevention 

and substance abuse 

� Sexual activity, e.g., STI/HIV transmission; abstinence; sexual orientation 

� Continue to develop sense of identity by clarifying values and beliefs 

� Discuss peer pressure and handling negative peer pressure 

� Social interaction 


� Good parenting practices 

� Discuss plans for the future, education 

� Follow the speed limit and drive responsibly 

� How their teenager is developing 




18 years: 


� Sexual activity 

� Peer pressure 



� How to access health care 

� Plan for future 

� Trusting own feelings and following feedback given by trusted friends and adults 

� How their young adult is developing 


20 years: 


� Sexual activity 

� Peer pressure 


� Respect the rights and needs of others 

� Educational activities 

� Plans for future 

� How their young adult is developing 




Illinois Tobacco Quitline 

http://www.quityes.org 

Smoking Cessation Information and Resources 

Five Major Steps to Intervention (The 5A’s) 

http://www.surgeongeneral.gov/tobacco/5steps.pdf 

Illinois Tobacco-Free Communities (IDPH) 

http://www.idph.state.il.us/TobaccoWeb site/pap.htm 

Tobacco (Illinois Lung Association) 

http://www.lungil.org/tobacco/ 

Smoking Cessation (NIH) 

http://www.nlm.nih.gov/medlineplus/smokingcessation.html 

Questions and Answers About Smoking Cessation 

http://www.cancer.gov/cancertopics/factsheet/Tobacco/cessation 

Smoking Cessation (American Heart Association) 

http://www.americanheart.org/presenter.jhtml?identifier=4731 

Smoking Cessation 

http://health.nih.gov/result.asp/607 

The Health Consequences of Smoking: A Report of the Surgeon General 

http://www.cdc.gov/Tobacco/sgr/sgr_2004/index.htm 

Women and Smoking: A Report of the Surgeon General 

http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001/ 

Secondhand Smoke 

http://www.cancer.org/docroot/PED/content/PED_10_2X_Secondhand_Smoke- 

Clean_Indoor_Air.asp?sitearea=PED 

Secondhand Smoke and Children Fact Sheet 

http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&B=39857 

Guidelines for Smoking Cessation 

http://www.guideline.gov/summary/summary.aspx?doc_id=3307&nbr=2533 

Tobacco Cessation Guideline 

http://www.surgeongeneral.gov/tobacco/default.htm 

Smoking Information for Health Professionals 

http://www.cancer.org/docroot/PED/PED_10_6.asp?sitearea=PED 

Fact Sheets: Tobacco/Smoking Cessation 

http://www.cancer.gov/cancertopics/factsheet/Tobacco 



Smoking Cessation: Integration of Behavioral and Drug Therapies 

http://www.aafp.org/afp/20020315/1107.html 

American Academy of Family Physicians 

Tobacco Cessation: Resources and Patient Education Materials 

http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/resources.html 

Counseling to Prevent Tobacco Use and Tobacco-Caused Diseases 

http://www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm#ref4 

Smoking Cessation – You Can Quit Smoking Now! 

http://www.surgeongeneral.gov/tobacco/ 

Quit Smoking 

http://www.cdc.gov/tobacco/quit_smoking/index.htm 

Quit Smoking 

http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33484 

Freedom From Smoking Online 

http://www.ffsonline.org 

The National Partnership to Help Pregnant Smokers Quit 

http://www.smokefreefamilies.org/ 

Smoking and Pregnancy 

http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33573 



Appendix 2 

Developmental Milestones 

Note: The developmental milestones below are recommended as minimal to be 

assessed, through surveillance, observation, and inquiry/discussions with parent(s), 

guardian(s), caretaker. The developmental milestones were developed 

in conjunction with: 

AAP’s Bright Futures: Guidelines for Health Supervision of Infants, Children, and 

Adolescents, 3rd Edition (2008) 

http://www.brightfutures.aap.org 

Caring for Your Baby and Young Child: Birth To Age 5, Steven Shelov, Robert E 

Hannermann 2004 American Academy of Pediatrics 

Behavioral and Developmental Pediatrics A Handbook for Primary Care, Steven Parker, 

Barry Zuckerman; Little, Brown and Company Boston 

http://www.edopc.org 

Healthy Steps for Young Children Program Multi Media Training & Resource Kit Toby 

Levine Communications, Inc. and the Boston University School of Medicine Department 

of Pediatrics 

http://www.healthysteps.org 

2- 4 weeks: 

Physical 

� Raises head momentarily when prone 

� Fixes on human face or brightly colored toys and follows with eyes 

� Has flexed posture; moves all extremities 

� Grasps an adult finger 

Social-Emotional 

� Responds to parent’s face and voice 

� Smiles spontaneously 

� Turns head in direction of parent’s voice 

� Tries to self-comfort by sucking on one or more fingers 

� Can sleep for three or four hours at a time; can stay awake for one hour 

Communication – Hearing and Vision 

� Responds to sound by blinking; crying; quieting; changing respiration; or showing 

startle response 

� Can be consoled most of the time by being spoken to or held 

� Cry to indicate hunger or discomfort 

2 months: 

Physical 

� Grasps rattle placed in hand 

� When prone (only when awake due to SIDS precaution), lifts head, neck and upper 

chest with support of forearms 

� Some head control in upright position 




� Makes eye contact 

� Social smiles; smiles responsively 

� Coos and reciprocal vocalization when spoken to 

� Demonstrates social interaction; follows moving person with eyes 

Communication – Hearing, Vision, Language 

� Shows interest in visual and auditory stimuli – will turn toward things that look and/or 

sound interesting 

4 months: 

Physical 

� Holds head high; raises body on hands when prone 

� Sits when supported 

� Controls head well 

� Stands when pulled upright 

� Plays with hands; holds rattle; reaches for objects; holds own hands 


� Smiles spontaneously 

� Coos; laughs; babbles 

� Demonstrates range of emotions 

� Initiates social contact; turns to voice 

� May sleep at least six hours 

� Able to comfort self, e.g., fall asleep by self 

� More expressive – communicates more with face and body 


� Looks at mobile, arms active 

� Follows object 180 degrees 

� Uses vowel and consonant sounds such as “dada” and “baba” 

6 months: 

Physical 

� Rolls both ways 

� Sits with support 

� Bears weight; stands with support 

� Transfers objects hand-to-hand 

� Shakes head 

� Points finger 

� Creeps or scoots on bottom 


� May show stranger anxiety 

� Reacts socially by smiling in response to someone else’s smile 

� Shows recognition of parents 

� Shows interest in toys 

� Starts to self-feed 




� Turns to sound and voice 

� Vocalizes single consonants (“dada”, “baba”) 

� May imitate sounds of speech 

� Babbles reciprocally 

Cognitive 

� Raking hand pattern 

� Grasps and mouths objects 

� Shakes, bangs, and drops a toy 

9 months: 

Physical 

� Sits independently 

� Reaches for objects with one hand 

� Pulls to stand 

� Stands holding on 

� Inferior pincer grasp; pokes with index finger 

� Bangs, throws and drops objects 


� Finger feeds 

� Starts to use cup 

� Can sleep through the night 

� Reaches for a familiar person and responds to others expressions of emotion 

� May show stranger anxiety 

� Enjoys interactive social games, e.g., peek-a-boo and pat-a-cake 

� Interested in mirror images 


� Imitates vocalizations; babbles 

� May say “dada” and “mama” nonspecifically 

� Responds to own name 

� Understands a few words, e.g., “no-no”; “bye-bye” 

� Turns towards sound with eyes and head movement 

� Babbles string of consonant; vowel and “sentences” 

Cognitive 

� Follows a point 

� Wave bye-bye 

� Finds a hidden object 

� Explores with hands and mouth 

12 months: 

Physical 

� Gets from sitting to crawling position 

� Pulls to stand 

� Stands alone 

� Cruises 

� May take a few steps alone 



� Has precise pincer grasp 

� Bangs two blocks together 

� Tries to scribble with pencil on paper 

� Takes objects in and out of container – can let go voluntarily 


� Recognizes caregiver’s voice 

� Obeys simple requests; waves “bye-bye” 

� Feeds self 

� Drinks from a cup 

� Shows emotions (fear, anxiety, affection) 

� Shy or anxious with strangers 

� Cries when mother or father leaves 

� Shows preference for certain people or toys 

� Prefers mother and/or regular caregiver over all others 

� Extends arm or leg when being dressed 

� Tests parental response to behavior 

� Repeats sounds and gestures for attention 

� Imitates – enjoys imitating people in his play 


� Points or gestures to indicates wants or get needs met 

� Has vocabulary of one to three words 

� Uses “mama” and “dada” correctly 

� Full color vision 

� Distance vision matures 

� Ability to track moving object 

� Say 1 – 3 words in addition to “mama” “dada” 

� Points with index finger 

� Stops eating and starts playing when full 

� Responds to simple verbal requests 

� Responds to “no” 

� Babbles with inflection 

� Understands simple command 

� Says “oh-oh” 

Cognitive 

� Actively look for hidden or dropped objects 

� Struggles to obtain object out of reach 

� Looks at correct picture when image is named 

� Imitates household activities 

� Stacks two blocks 

15 months: 

Physical 

� Walks alone; bends over; may run 

� Crawls up stairs 

� Points to one or more body parts 

� Feeds self with fingers; drinks from cup 




� Listens to a story 

� Checks parent facial expression 

� Begins to show empathy 

� Fears new things including new foods 

� Responds to encouragement to eat even when full to please adult 


� Has vocabulary of three to ten words 

� Indicates wants by pointing or grunting 

� Points to indicate to another object of interest 

� Temper tantrums out of frustration 

� Refuses to eat when not hungry 

Cognitive 

� Stacks 2-3 blocks 

� Points to one or more body parts 

� Can remove some clothing 

� Understands cause and effect and problem solves 

� Uses symbolic play 

� Imitates social games 

18 months: 

Physical 

� Likes to climb and run 

� Walks quickly or runs stiffly 

� Walks backwards 

� Climbs into chair 

� Sits in chair 

� Throws/kicks ball 

� Stacks three or four blocks 

� Eats with utensils 

� Drinks from cup 

� Brushes teeth with assistance 

� Washes and dries hands with assistance 


� Uses a spoon and cup 

� Shows affection by hug and kisses 

� Wants comfort item in bed, e.g., doll; blanket 

� Attracts parental attention by looks and gestures 

� Plays cooperatively for brief sessions 

� Plays pretend 

� Clinging to parent returns 

� Enjoys looking at self in mirror 


� Has a vocabulary of 15-20 words; uses two word phrases; imitates words 

� Listens to a story; looks at pictures; names objects 

� Answers simple questions by pointing 



� Follows simple directions/rules 

� Names one picture 

� Names two colors 

� Points to four pictures 

� Uses two to three word sentences 

� Says 15 – 20 words 

� Uses two-word phrases 

Cognitive 

� Plays with toys appropriately, e.g., pulls a pull toy; cuddles a doll 

� Scribbles spontaneously; imitates crayon strokes 

� Dumps object from bottle without demonstration 

� Helps dress self 

� Places circle; square shapes in a puzzle 

� Stacks 4 – 6 blocks 

� Zips and unzips 

� Points to some body parts 

24 months: 

Physical 

� Up and down steps holding on with one hand; one step at a time 

� Climbs onto and down from furniture unassisted 

� Jumps; runs 

� Throws ball overhand 

� Stands on one foot with little support 

� Puts on clothing; undress self 

� Washes hands 

� Strings beads 

� Builds a tower of 6 – 8 blocks 

� Shows handedness 

� Helps prepare food, e.g., scrub; tear; break; dip; snap 

� Begins to show signs of toilet training readiness 

� Turns pages of book one at a time 


� Parallel play dominant 

� Possessive with toys 

� Separation anxiety from parents 

� Cooperative (sometimes) 

� Plays with joy 

� Spontaneously shows sense of humor 

� Enjoys playing next to other children 

� Offers a toy 

� Responds to encouragement to eat to please adult 

� Explores independently with confidence 


� Vocabulary 20 - 5 0+ words 

� Speaks 2 – 4 word sentences that include verbs, adjectives, and adverbs 

� Understands pronouns 



� Speech should be intelligible to parents 

� Can follow two-step commands 

� Can name some body parts 

� Dawdles when not hungry 

Cognitive 

� Makes or imitates horizontal and circular strokes with crayon 

� Imitates adults 

� Increasing attention span 

3 years: 

Physical 

� Balances on one foot for 2 seconds 

� Rides a tricycle, with or without training wheels 

� Alternates feet ascending stairs 

� Copies a circle and a cross 

� Pours liquid 

� Uses a fork 

� Serves food from a bowl using child size utensils 

� Toilet trained 

� Uses a blunt scissors 

� Dresses and undresses self (may need help with fastening) 


� Can follow directions 

� Pretend play well developed (imagines self as a character; uses toys as props) 

� Has words for feelings 

� Shows empathy 

� Approach and play with familiar children 

� Plays well with others 

� Understands concept of “mine” and “his/hers” 

� Begins to share toys 

� Takes turns 

� Talks for objects 

� Responds to encouragement to eat even when full to please adult 

� Separates easily from parents 

� Objects to major changes in routine 


� Demonstrates speech that is mostly intelligible 

� Plays show and tell 

� Uses three word sentences 

� Talks clearly and is understandable most of time 

� Says at least 250 words 

� Knows all pronouns 

Cognitive 

� Copies circle and cross 

� Visually discriminates colors 

� Matches colors and sorts by category, shape 



� Names colors 

� Identifies food by name 

� Asks “why” questions 

� Has some self care skills, e.g., feeding and dressing self 

� Understands concept of “two” 

� Count to five 

� Talks about the future 

� Knows name, age and gender 

� Uses own name and others 

� Gender identity established 

� Names six body parts 

� Name missing object 

� Makes mechanical toys work 

� Completes a 3 – 4 piece puzzle 

4 years: 

Physical 

� Hops, jumps forward 

� Runs easily 

� Alternates feet when climbing stairs 

� Balances on each foot for five seconds 

� Climbs 

� Builds tower of 10 or more blocks 

� Throws overhand 

� Ability to cut and paste 

� Peels, cuts, mashes and rolls food 

� Holds pencil in writing position 

� Begins to copy some capital letters 

� Screws and unscrews jars, nuts and bolts 

� Turns rotating handle 


� Plays board/card games 

� Can talk about daily activities and experiences 

� Often cannot distinguish fantasy from reality 

� Imagines that many unfamiliar images may be “monsters” 

� Make believe play; imaginary playmates 

� Puts away own toys 

� Dresses and undresses self – buttons 

� Brushes teeth without assistance 

� Cooperative play with group 

� More independent 

� Play “mom” or “dad” 

� Negotiates solutions to conflicts 

� Views self as a whole person involving body, mind, and feelings 


� Sings a song 

� Speaks in sentences of five to six words 

� Speaks clearly enough for strangers to understand 



� Tells stories 

� Talking gets in the way of eating (prefers to talk) 

� Has mastered some basic rules of grammar 

Cognitive 

� Gives first and last name 

� Draws a three part person 

� Says a poem 

� Strong food preferences 

� Relates health to own body 

� Understands right and wrong based on consequences not intentions 

� Copies a square 

� Draws circles and squares 

� Correctly names some colors 

� Begins to have clear sense of time 

� Follows a three-part command 

� Understands the concept of “same” and “different” 

� Engages in fantasy play 

5 years: 

Physical 

� Dresses and undresses self without assist 

� Ties shoelaces 

� Heel-to-toe walk 

� Walks downstairs, using alternative feet 

� Hops on one foot 

� Begins to skip alternating feet 

� Swings 

� Can use scissors to cut a straight line 

� Traces within lines 

� Draws a person with body 

� Prints some letters 

� Uses fork, spoon, and sometime table knife 

� Copies triangle and other shapes 

� Can handle snaps, buckles, buttons, zippers; begins to tie shoes 

� Independent toileting 


� Plays make believe and dress up 

� Plays and shares with others 

� Wants to please friends 

� More likely to agree on rules 

� Likes to sing, dance, and act 

� Shows more independence 

� Able to function in structured group with rules 

� Shows concern and sympathy for others 

� Initiates sharing and taking turns 

� Aware of gender 

� Able to distinguish fantasy from reality 

� Sometime demanding; sometimes eagerly cooperative 




� Speaks in sentences of more than five words phrases that are understood by others 

� Understands opposites 

� Recalls parts of stories, tells longer stories 

� Asks meaning of words 

� Describes pictures and experiences 

� Uses appropriate verb tense and grammar 

� Recognizes simple jokes, riddles, absurdities (Do cats fly?) 

Cognitive 

� Knows own address and phone number 

� Recognizes four colors and common shapes 

� Copies simple shapes (e.g., triangle or square) 

� Prints a few letters and numbers 

� Draws a person with head, body, arm and legs 

� Counts on fingers or ten or more objects 

� Better understands the concept of time 

� Knows about things used in home (money, food, appliances) 

Kindergarten Checklist 

There is no simple method for determining that a child is ready for kindergarten. But this 

list from a child development specialist may help parents evaluate their children’s 

developmental level. These developmental skills are important for a child if he is to 

function happily in the kindergarten classroom. 

Speech and language: 

� Asks meaning of words 

� Describes pictures and experiences 

� Uses appropriate verb tense and grammar 

� Recognizes simple jokes, riddles, absurdities (Do cats fly?) 

Gross motor coordination: 

� Walks downstairs, using alternative feet 

� Hops on one foot 

� Jumps along a 6-foot line with both feet 

� Walks scissor steps across a line 

� Begins to skip alternating feet 

Fine motor coordination: 

� Can use scissors to cut a straight line 

� Copies a circle square and cross 

� Draws a person fully with body and four limbs 

� Traces within lines 

Social and emotional: 

� Can handle snaps, buckles, buttons, zippers and begins to tie shoes 

� Independent toileting; dresses and undresses independently 

� Able to function in structured group with rules 

� Shows concern and sympathy for others 

� Initiates sharing and taking turns 



Appendix 3 

Mental Health Screening and Referral Resources 

General Information: 

Illinois children enrolled in the Department’s Medical Programs are eligible for 

comprehensive mental health services, if medically indicated. The Department and the 

IDHS, Division of Mental Health, have collaborated to develop a system to ensure that 

children in need of mental health services will be appropriately referred and assessed 

for mental health treatment. 

This Appendix 3 will assist the provider in completing the Healthy Kids Mental Health 

Screen form, the mental health portion of the Healthy Kids periodic screening. The 

Mental Health Screen is for use with children ages 3 through 20. There are 

recommended questions that will enable the provider to complete the Healthy Kids 

Mental Health Screen. Each of the questions is general in nature and is offered as an 

illustrative example of the information sought. It is suggested that the interviewer modify 

the question as indicated by the age of the child and understanding of the informant. 

The questions should assist the evaluator in: 

• Determining whether cognitive functioning/mental status is age-appropriate 

• Whether behavior is appropriate (such as goal-directed with response to 

controls) 

• Whether affect is appropriate 

Previous mental health treatment should be recorded on the Healthy Kids Mental Health 

Screen form. The back of the Healthy Kids Mental Health Screen form contains a 

section relating to the child’s medical history, which may impact mental health or 

emotional development. 

Questions regarding maltreatment or possible maltreatment of the child should be 

addressed. For children over the age of three it is recommended that the maltreatment 

questions be asked of the child and their parents or caregiver separately. 

It is important to note that the guidelines regarding maltreatment DO NOT suggest that 

in the event the provider/evaluator learns of, or suspects current maltreatment, that the 

provider is removed from professional responsibility for reporting abuse of neglect in lieu 

of making a referral to the Mental Health provider. All suspected abuse or neglect 

should be immediately reported to: 

1-800-25ABUSE. 

When completing a referral to the Mental Health provider, please keep in mind that the 

provider’s task is to identify behaviors and concerns that will assist the mental health 

professional in understanding the nature of the child’s problem. Whenever the 

parent/caregiver, child or provider perceive a problem to be in existence and outside a 

“normal range” in extent or intensity, mark all behaviors/symptoms that apply. 

Signs or symptoms may vary in severity, frequency, onset or duration; all of which are 

important issues in determining whether to refer or not. 



The Healthy Kids Mental Health Screen (HFS 3411B) can be ordered by providers from 

the HFS Warehouse: 

2946 Old Rochester Road 

Springfield, Illinois 62703-5659 

All requests must be received on the HFS 1517 (R-9-06). This form may be obtained 

from HFS’ Web site or email address: http://www.hfs.illinois.gov/forms/ 

The form may be faxed to (217) 557-6800. 

Additional information about ordering Department forms can be found in Chapter 100 - 

General Policy and Procedures, 112.43 Ordering of Claims Forms and Envelopes. 

Decision-Making Regarding Mental Health Referrals 

Sorting Out the Levels of Risk 

In making a decision regarding referral, many of the symptoms/behaviors are significant 

enough to trigger an immediate referral. You will find these printed in bold on the 

checklist form. They include: 

• Suicidal Behavior or Suicidal Ideation 

• Signs of Self Destructive Behavior 

• Evidence of Abuse or Neglect Affecting Mental/Emotional Health 

• Sexually Victimizes Others or Has Been Sexually Abused 

• Victimization 

• Evidence of Delusions or Hallucinations 

• Appears Depressed or Hyperactive 

• Demonstrates Signs of Eating or Sleeping Disorders 

• Intentionally hurts other People or Animals 

• Engages in fire setting 

• Substance Abuse in Conjunction With Other Mental Health Concerns 

The presence of any of these symptoms or behaviors may signal that the child is in 

crisis and are considered potent clinical indicators for possible referral to the appropriate 

mental health provider so that a mental health assessment, and if appropriate, mental 

health treatment may be obtained. 

Children with other behaviors identified on the Healthy Kids Mental Health Screen, 

which in combination might indicate a mental or emotional disorder should be referred 

for a mental health assessment. 

Referrals under the EPSDT program requires that the provider: 

• Obtain written consent of the parent/guardian to release information to the 

mental health service provider 

• Make contact with an approved Mental Health Service Provider and set an 

appointment 

• Communicate with the child and Parent/Guardian, the appointment time and 

location before they leave your office following the screening 

• Send copies of your Mental Health Screen to the referral source 

• Receive from the referral source within a reasonable amount of time (e.g. ten 

days following the appointment date) notification as to the disposition 



(show/no show) of the appointment, including any preliminary diagnosis and 

recommendations 

The Mental Health Provider will, with the written permission of the parent/guardian: 

• Receive the referral 

• Notify physician if the appointment was not kept and has been re-scheduled. 

If the child has an identified case manager, the case manager should be 

notified for the purpose of follow-up 

• Assess the client 

• Provide continuing feedback to the referring physician as indicated (e.g., 

significant changes in the treatment plans, if hospitalized, referred for 

residential treatment, medication changes) 

HEALTHY KIDS MENTAL HEALTH SCREEN 

Recommended Questions to Assess Checklist Indicators (Ages 3 through 20) 

In order to accurately complete the Healthy Kids Mental Health Screening form, the 

following simplified questions covering the specific areas of concern may be helpful to 

the screener. Although these are written questions to be asked of the parent/guardian, 

they can easily be adapted to first person for older children and adolescents. It is helpful 

to have the parent or child/adolescent provide examples (specific situations). Age 

appropriateness should be considered for all question asked. 

Introductory Questions: Do you have concerns about this child? What concerns you 

most about this child? (These questions might give you an indication of what areas on 

the Mental Health Screen should be more closely explored.) 

THINKING: 

1. Delusions - Does your child: have “unusual” thoughts or behaviors that concern 

you or tend to be different from what most other children his age believes; 

believe that he has some unusual ability or power (not related to his age or 

developmental period)? 

2. Hallucinations - Does your child hear, see, taste, touch or smell things that are 

not really there? 

3. Paranoia - Is your child overly suspicious of others, or does he feel that others 

are out to get him? 

4. Obsessive Ideation - Does your child: seem to think about or talk about the 

same thing most of the time; seem to be preoccupied with things such as death, 

sex, bodily functions, extreme cleanliness, or other things that are unusual for 

someone his age. 

5. Frequent Memory Loss - Does your child often tend to forget things most other 

children his age would remember that is not related to discipline or punishment? 



6. Confusion - Does your child often seem to be confused, have difficulty following 

or understanding simple directions, or seem easily frustrated by 

instructions/directions? 

7. Easily Distracted - When your child is working on something, does your child 

have trouble staying on task? Is she/he bothered or distracted by sounds or 

things in his/her environment? 

8. Difficulty Concentrating - Does your child: often begin things and fail to finish 

them; have difficulty in finishing one thing prior to beginning another; move from 

activity to activity without apparent purpose? 

FEELING: 

1. Depressed Mood (Sad) - Does your child seem to often be irritable, depressed 

or sad? Has your child lost interest in things he used to enjoy? 

2. Inappropriate Affect - Does your child seem, without a reason, to often be 

happier and more energetic than most children his age or, be sad or angry when 

there seems no reason to be? 

3. Anxiety, Agitation - Does your child appear to be worried, frightened, nervous 

or upset easily or often? 

4. Anger - Is your child often easily angered or seem to often be mad? 

5. Apathy - Does your child show a lack of interest in things he once enjoyed? 

Describe onset. 

6. Low Self-Esteem - Does your child think he is less important, not as pretty or 

smart as other kids his/her age 

7. Self-Critical - Does your child say things that “puts himself down”? 

8. Cries Excessively - Does your child cry often over little things or for no apparent 

reason? 

9. Cries too little - Does your child not cry when you think he should? 

10. Emotionless, Flat Affect - Does your child fail to show feelings such as 

sadness, happiness or anger as often as other children his age? 

11. Feels Out of Control - Does your child act as though he is losing control of what 

he says, does or thinks? Does he say he fears losing control or “going crazy”? 

BEHAVIOR: 

1. Intentionally Hurts others - Does your child seem to intentionally hurt others? 

How often? In what ways? 



2. Self-Destructive - Does your child intentionally do things to hurt himself? Does 

he often engage in dangerous or “risky” behaviors that might lead to injury or 

trouble? Have marks or bruises on herself that you suspect are self-inflicted? 

3. Intentionally Hurts Animals - Does your child do things to intentionally hurt 

animals? 

4. Sexually Victimizes Others - Has your child forced/made others do sexual 

things? 

5. Sets Fires - Does your child play with fire or been known to set fires? Explain. 

6. Compulsive Behavior - Does your child do the same thing repeatedly or not 

seem able to stop an activity or behavior once it is started? 

7. Destructive Behavior - Does your child destroy other people’s things on 

purpose? His own things? 

8. Overreacts - Do little things bother your child to the point where he responds 

more strongly than other children? 

9. Overactive - Does your child appear to often have trouble sitting still when 

compared to other children his age? 

10. Listless - Does your child seem to easily lose interest or energy for doing 

things? 

11. Argumentative - Does your child often argue or disagree with others? 

12. Refuses to Talk - Does your child refuse to talk (or ignore people) when spoken 

to? 

SOCIAL INTERACTION: 

1. Home Problems: 

a. Does your child have relationship problems with parents/guardians? 

b. Does your child have more problems with siblings than most children? 

c. Does your child have problems with others living in your house or other 

relatives? 

2. Community Interaction: 

a. Has your child stolen on more than one occasion? 

b. Does your child lie often? 

c. Has your child come into contact with the police because of his behavior? Is he 

on probation, court supervision or parole? 

3. Defies Authority - Does your child have trouble getting along with people in 

authority (teachers, police, parents, etc.)? 

4. Friendless, Isolated - Does your child complain of not having friends, of others 

“picking on” him or does he play alone most of the time? 



5. Immature - Does your child often act like children of a much younger age? 

6. Excessive Clinging - Does your child show excessive fear when strangers are 

around? Refuse to stay with babysitters? Cling to you often? 

7. Withdrawn/Unresponsive - Does your child: prefer to play with things rather 

than people; ignore others even when spoken to? Have there been any recent 

changes in the way your child interacts with others including less involvement 

with others? Has your child’s ability or willingness to communicate/talk with 

others changed recently? 

8. Inattentive - Does your child seem to ignore things taking place around him? 

9. School Problems: 

a. Does your child have many fights at school? 

b. Is (has) your child failing in school? Are your child’s grades much lower than 

he is capable of? 

c. Has your child been expelled/suspended from school for behavior? 

d. Is your child absent from school often? Does your child refuse to attend 

school? Does your child skip school (truancy)? 

e. Is your child in a special education class for behavioral or emotional problems? 

f. Does the child’s age minus his grade equal 5 or 6? If not, does it indicate the 

child is below his normal grade level in school? Is so, why? 

Age Minus Grade 

10 - 4 = 6 (age appropriate) 

10 - 2 = 8 (not age appropriate) 

PHYSICAL PROBLEMS: Before checking any of these, the physician should rule out 

any physical disorders, which could account for the problem. 

1. Eating Disorders - Does your child do any of the following: a) Refuse to eat 

often? b) Often overeat? c) Vomit often following a meal? d) Have diarrhea 

often? e) Complain often of stomachache? 

2. Sleeping Disorders - Does your child do any of the following? 

a) Have difficulty falling asleep? 

b) Have difficulty staying asleep? 

c) Feel tired most every day? 

d) Sleep walk? 

e) Have bad dreams or nightmares frequently? 

f) Cannot be awakened from a bad dream? 

g) Snore a lot? 

h) Move violently, jerk, twitch or grind teeth during the night? 

3. Enuresis - Does your child wet the bed at night or his clothing during the day? 

4. Encopresis - Does your child soil his pants in bed or during the day? 



5. Frequent Somatic Complaints - Does your child often complain of body pains 

or of being sick? 

6. Drastic Weight Change - Has your child gained or lost a lot of weight lately? 

(more than 10% of his body weight?) 

7. Lethargic - Does your child appear to be often tired or have little energy? 

The screener should provide comments for any item checked in this section in the 

Comment section on the backside of the form. 

The following information may be obtained by interview or observation: 

LIFE CHANGES: (Stressors) (Last Year) 

Victimized/Neglect - physical, sexual, financial (robbery, etc.), emotional, abuse or 

neglect (provide comments). Examples: 

• Death of Family Member or close friend - indicate relationship 

• New School - change of school (indicate number of changes in past three 

years) 

• Loss of Relationship - indicate relationship and cause 

• Serious Illness/Injury - of self or family member (indicate nature of illness or 

injury) 

• Incarceration of Parent - Parent or guardian placed in jail or prison 

• Loss of Job - self or family member (indicate impact on family) 

• Economic Loss - fire, accident, repossession, etc. 

• Residence - include foster placement, moves (indicate number) 

• Witnessed a Violent Crime - personally viewed the commission of a crime of 

violence or the injuries/death of the victim shortly thereafter or exposure to 

crime of violence in parent, caregiver or sibling? 

SUICIDE IDEATION: 

1. Ideation/Plan - Is your child talking to you about ending his life, or wishing he 

were never alive or born, or about life being hopeless, of wanting to do serious 

self-harm? Does he talk about death often? Has your child ever spoken of a plan 

to kill himself? If so; how, when, and where has he indicated he will do it? 

2. Gestures - Have there been suicidal gestures (threats, notes, scratches on 

wrists, etc.) within the past year. Has your child done anything else that makes 

you think he seriously wants to end his life? 

3. Attempts - Have there been attempts (overdoses, hanging, etc.) that were 

unsuccessful anytime during his life? Has your child ever intentionally harmed 

himself? 

The screener should comment on any suicidal indications in the Comment section on 

the back of the form. 



SUBSTANCE ABUSE: 

Do you suspect your child has experimented with drugs or alcohol? What makes you 

think that? What drugs and alcohol usage has occurred, if any? Indicates types, 

amounts and frequency. 

MEDICAL ISSUES: 

Is there a significant illness or injury in the child’s medical history that you feel affects 

his mental/emotional health? (Indicate medical diagnoses, current medications, 

hospitalizations, major illnesses, surgeries, severe injuries, significant developmental 

delays, out-of-home placements and significant family crises.) 

ABUSE/NEGLECT: 

Is there anything that causes you to suspect child abuse or neglect? (SPECIFY) 

Report immediately (1-800-25-ABUSE) 



Appendix 3 

Healthy Kids Mental Health Screen 

Ages 3 Through 20 

Illinois Department of Healthcare and Family Services 

Bureau of Maternal and Child Health Promotion 

CHILD PARENT/CAREGIVER SCREENER 

NAME NAME NAME_____________________ 

BIRTH DATE _______AGE_____ ADDRESS________________ PHYSICIAN/CLINIC__________ 

GRADE____ MEDICAID NO. ___ PHONE __________________ ADDRESS/PHONE__________ 

INSTRUCTIONS: Question the child, parent/guardian, and check medical records. 

Based on age appropriateness, mark those that are currently 

indicated unless otherwise instructed. Make a referral for a Mental Health Assessment 

when necessary. (Refer to Provider Handbook for instructions.) STOP! If the child has 

already been referred or is currently receiving treatment do not continue. 

Do you have any concerns about this child? What about this child concerns you most? 

THINKING 

___Delusions 

___Hallucinations 

___Paranoia 

___Obsessive Ideation 

___Frequent Memory Loss 

___Confusion 

___Easily Distracted 

___Difficulty Concentrating 

___None of the Above 

BEHAVIOR 

___Intentionally Hurts 

Others 

___Self-Destructive 

___Intentionally Hurts 

Animals 

___Sexually Victimizes 

Others 

___Sets Fires 

___Compulsive Behaviors 

___Destructive Behaviors 

___Overreacts 

___Overactive 

___Listless 

___Argumentative 

___Refuses to Talk 


FEELING 

___Depressed Mood 

(Sad or irritable) 

___Inappropriate Affect 

___Anxiety, Agitation 

___Anger 

___Apathy 

___Low Self-Esteem 

___Self-Critical 

___Cries Excessively 

___Cries Too Little 

___Emotionless, Flat 

Affect 

___Feels Out of Control 


LIFE CHANGES (past 

year) 

___Victimized/Neglect 

___Death of Family 

Member 

___New School 

___Lost Relationship 

___Serious Illness/Injury 

___Incarceration of a 

Parent 

___Loss of Job 

___Economic Loss 

___Residence 

___Witnessed a Violent 

Crime 


PHYSICAL (Rule out physical 

disorder) 

___Eating Disorder 

(Specify) 

___Sleep Disorder 

(Specify) 

___Enuresis 

___Encopresis 

___Frequent Somatic 

___Complaints 

___Drastic Weight Change 

___Lethargic 


SUICIDE ASSESSMENT 

(N/A) 

___Ideation/ Plan (current) 

___Gestures (past year) 

___Attempts (during lifetime) 

Comment on back for any 

item checked under 

Physical or Suicide. 

SUBSTANCE ABUSE (N/A) 

Drug of Choice: 

Amount: 

Frequency: 



SOCIAL 

___Problems at home 

___Parents 

___Siblings 

___Others 

___Community Interaction 

___Stealing 

___Chronic Lying 

___Police Involved 

___Defies Authority 

___Friendless, Isolated 

___Immature 

___Excessive Clinging 

___Withdrawn/Unresponsive 

___Inattentive 

___School Problems 

___Excessive Fighting 

___Failure, Grades 

___Expulsion 

___Truancy 

___Special Ed. 

(Behavior/Emotional 

Problems) 

___Child’s Age 

(Minus) Grade = 5 or 6 

__None of the above 

MEDICAL ISSUES: Mark any of the following 

that are applicable. Has the child ever or do they 

currently have any of the following: (Provide 

narrative under comments) 

CHRONIC CONDITIONS 

___Diabetes 

___Heart Condition 

___Asthma 

___Tuberculosis 

___Urinary Tract Condition 

___Anemia 

___Cancer 

___G.I. Condition 

___Other (specify) 

HEALTH HISTORY 

___Major Surgery (specify) 

___Head Injury (medically evaluated) 

___Other Injury 

___Medical Hospitalization (past 3 years) 

FAMILY SITUATION 

___Out of Home Placement 

___Family History of Mental Illness 

___Family History of Substance Abuse 

___Child or Family Received Counseling (past 3 

years) 

PSYCHIATRIC HOSPITALIZATION during the past three years ____child ___family 

member. 

List other MEDICAL CONDITIONS that may impact mental or emotional development: 

Is the child currently on MEDICATION? If so, specify medication and dosages: 

COMMENTS: (comment on all items checked under “Physical” or “Suicide”) 

Note: Bolded items may require an immediate referral. 

_____CHECK IF PARENT OR GUARDIAN REQUESTS A REFERRAL. 

Suspected Child ABUSE and NEGLECT must be reported to DCFS immediately! 

1-800-25ABUSE. 



The PHYSICIAN conducting the Healthy Kids Mental Health Screen: 

1. Makes an appointment with a Mental Health provider when indicated. The 

appointment should be made while the child is at your office and the information 

about the appointment should be given to the parent/caregiver. 

2. Sends a copy of this form to the Mental Health provider. 

REFERRAL TO: _______________________ DATE_________ TIME______________ 

DATE CLIENT NOTIFIED OF APPOINTMENT_________ 

BY WHOM____________ 

The MENTAL HEALTH PROVIDER conducting the mental health assessment, with the 

signed consent of the parent/guardian: 

1. Sends a copy of this form to the referring physician once the assessment has 

been completed indicating recommended services. 

2. Informs the referring physician of the missed or rescheduled appointments. 

3. Reports the client’s progress, change in treatment plans on a quarterly basis until 

case closure. 

To be completed by the MENTAL HEALTH PROVIDER ONLY and returned to the 

referring physician. 

DATE OF ASSESSMENT___________________ DIAGNOSIS__________________ 

RECOMMENDED SERVICES: 





APPENDIX 3 

Department of Human Services/Division of Mental Health 

Certified Medicaid Providers by County 

Adams 

Chaddock 

205 South 24 th Street 

Quincy, IL 62301 

217-222-0034 

Alexander 

Delta Center 

1400 Commercial Avenue 

Cairo, IL 62914 

618-734-2665 

Boone 

Janet Wattles Center 

475 Southtowne Drive 

Belvidere, IL 61108 

815-544-4849 

Bureau 

North Central Behavioral Health 

526 Bureau Valley Parkway 

Princeton, IL 61356 

815-875-4458 

Carroll 

Sinnissippi Centers Inc 

1122 Healthcare Drive 

Mt. Carroll, IL 61053 

815-244-1376 

Champaign 

Crosspoint Human Services 

501 West Church 

Champaign, IL 61821 

217-351-9744 

Champaign 

Mental Health Center of Champaign 

County 

1801 Fox Drive 


217-398-8080 

Adams 

Transitions of Western IL 

4409 Maine Street, Box 3246 


217-223-0413 

Bond 

Bond County Health 

Department/Prairie Counseling Center 

503 South Prairie 

Greenville, IL 62246 

618-664-1455 

Brown 

Mental Health Centers of Western IL 

700 Southeast Cross Street 

Mt. Sterling, IL 62353 

217-773-3325 

Calhoun 

Tri County Counseling Center 

220 East County Road, P.O. Box 381 

Jerseyville, IL 62052 

618-498-9587 

Cass 

Cass County Mental Health 

Association 

121 East 2nd Street 

Beardstown, IL 62618 

217-323-2980 

Champaign 

Catholic Social Service 

1315A Curt Drive 


217-352-5179 

Champaign 

Cunningham Children’s Home 

1301 North Cunningham Avenue 

Urbana, IL 61802 

217-367-3728 



Champaign 

The Pavilion Foundation 

809 West Church Street 


217-373-1700 

Christian 

Kemmerer Village 

RR1 Box 12C 

Assumption, IL 62510 

217-226-4451 

217-226-4012 

Clay 

South East Counseling Centers 

118 West North Avenue 

Flora, IL 62839 

618-662-2289 

Coles 

Life Link 

750 Broadway Avenue East 

Mattoon, IL 61938 

217-238-5700 

Cook 

Ada S McKinley Intervention Services 

2715 West 63 rd Street 

Chicago, IL 60629 

773-434-5577 

Cook 

Alexian Center for Mental Health 

3350 Salt Creek Lane #114 

Arlington Heights, IL 60005 

847-952-7460 

Cook 

Asian Human Services of Chicago 

4753 North Broadway, Suite 700 


773-728-2235 

Cook 

Aunt Martha’s Youth Service Center 

233 West Joe Orr Road 

Chicago Heights, IL 60411 

708-754-1044 

Christian 

Christian County Mental Health 

Association 

P.O. Box 438 

730 North Pawnee 

Taylorville, IL 62568 

217-824-4905 

Clark 

Human Resource Center of Edgar and 

Clark Counties 


Marshall, IL 62441 

217-826-6212 

Clinton 

Community Resource Center 

580 8 th Street 

Carlyle, IL 62231 

618-594-4581 

Cook 

Abraham Lincoln Center 

3858 South Cottage Grove 


773-285-1390 

Cook 

Advocate IL Masonic Behavioral Health 

938 West Nelson Street 


773-296-3220 

Cook 

Anixter Center 

2032 North Clybourn Avenue 


773-929-8200 

Cook 

Association House 

1116 North Kedzie Avenue 


773-772-8009 

Cook 

Beacon Therapeutic Treatment and 

Diagnostic Center 

10650 South Longwood Drive 


773-881-1005 



Cook 

Back of the Yards Mental Health 

Center 

4313 South Ashland 


312-747-3560 

Cook 

Catholic Charities of the Archdiocese of 

Chicago 

721 North LaSalle Street, 6 th Floor 


312-655-7700 

Cook 

Chicago Department of Public Health 

Division of Mental Health 

333 South State Street, 2 nd Floor 


312-747-9387 

Cook 

Circle Family Care 

5002 West Madison Street 


773-379-1000 

Cook 

Community Mental Health Center 

8704 South Constance Avenue 


773-734-4033 

Cook 

Counseling Center of Lakeview 

3225 North Sheffield 


773-549-5886 

Cook 

Englewood Mental Health Center 



312-747-7496 

Cook 

Evanston Northwest Healthcare OP 

Psychiatric Center 

2650 Ridge Avenue 

Evanston, IL 60201 

847-570-2720 

Cook 

Bobby E Wright Behavioral Health 

Center 

9 South Kedzie 


773-722-7900 

Cook 

Center for Mental Health and Deafness 

614 Anthony Trail 

Northbrook, IL 60062 

847-509-8260 

Cook 

Children’s Home and Aid 

125 South Wacker Drive 



Cook 

Community Counseling Centers 

Of Chicago 

4740 North Clark Street 


773-769-0205 

Cook 

Cook County Adult Probation 

2650 California 


773-869-3333 

Cook 

De Paul University Community Mental 

Health Center 

2219 North Kenmore Avenue 


773-325-7780 

Cook 

ERIC Family Services Inc 

6120 West North Avenue, Suite 202 


773-745-3742 

Cook 

Family Services Association 

1535 Burgundy Parkway 

Streamwood, IL 60107 

847-695-3680 



Cook 

Family Services and Mental Health 

Center 

Oak Park/River Forrest 

120 South Marion Street 

Oak Park, IL 60302 

708-383-7500 

Cook 

Grand Prairie Services 

19530 South Kedzie Avenue 

Flossmoor, IL 60422 


Cook 

Heartland Health Outreach, Inc 

4730 North Winthrop 

Chicago, Il 60640 

773-506-2379 

Cook 

HRDI Women’s Residential 

6701 South Elizabeth 

Chicago, IL 

773-651-2720 

Cook 

Housing Options for the Mentally Ill in 

Evanston 

1132 Florence Avenue 


847-866-6144 

Cook 

Infant Welfare Society of Chicago 

3600 West Fullerton Avenue 


773-782-2800 

Cook 

Josselyn Center for Mental Health 

405 Central 

Northfield, IL 60093 

847-441-5600 

Cook 

Kaleidoscope Inc 

1340 South Damen Avenue 



Cook 

Family Service and Mental Health 

Council of Cicero 

5341 West Cermak Road 

Cicero, IL 60804 

708-656-6430 

Cook 

Habilitative Systems, Inc. 

415 South Kilpatrick Street 


773-261-2252 

Cook 

Hephzibah Children’s Association 

946 North Boulevard 


708-649-7100 

Cook 

HRDI Children’s Residential 

11352 South State 


773-785-4955 

Cook 

Human Resources Development 

Institute 

340 East 51 st Street 


773-869-0300 

Cook 

Jewish Child and Family Services 

216 West Jackson Boulevard 


312-357-4800 

Cook 

Juvenile Protective Association 

1707 North Halsted Street 


312-440-1203 

Cook 

Lawndale Mental Health Center 

1201 South Campbell 


312-746-5905 



Cook 

Lawrence Hall Youth Services 

4833 North Francisco Avenue 


773-769-3500 

Cook 

Little City Foundation 

1760 West Algonquin Road 

Palatine, IL 60067 

847-358-5510 

Cook 

Lutheran Social Services of IL 

1001 East Touhy Avenue, Suite 170 

Des Plaines, IL 60018 

847-390-1468 

Cook 

Maine Center for Mental Health 

819 Busse Highway 

Park Ridge, IL 60068 

847-696-1570 

Cook 

Mercy Hospital and Medical Center 

2525 South Michigan 


312-567-2295 

Cook 

Metropolitan Family Services 

1 North Dearborn, Suite1000 


312-986-4000 

Cook 

New Direction Outreach 

6857 South State Street 


773-483-2226 

Cook 

Northwest Mental Health Center 

2354 North Milwaukee 


312-744-0993 

Cook 

Leyden Family Services and Mental 

Health Center 

10001 West Grand Avenue 

Franklin Park, IL 60131 

847-451-0330 

Cook 

LSSI Mental Health Service 

4840 West Byron Street 


773-282-7800 

Cook 

Lydia Home Association 

4300 West Irving Park Road 


773-736-1447 

Cook 

Maryville Academy 

1150 North River Road 


847-294-1701 

Cook 

Methodist Youth Services, Inc 

954 West Washington, 4 th Floor 

East Chicago, IL 60607 

312-733-8810 

Cook 

Mt. Sinai Hospital and Medical Center 

2653 West Ogden 


773-257-6672 

Cook 

North River Mental Health Center 

5801 North Pulaski Road 


312-744-1906 

Cook 

Northwestern Memorial Hospital 

446 East Ontario, Room 7-244 


312-926-8021 



Cook 

Pillars Community Services 

6918 Windsor Avenue 

Berwyn, IL 60402 

708-795-4800 

Cook 

Proviso Family Services, Inc 

(Resurrection Behavioral Health) 

1820 South 25 th Avenue 

Broadview, IL 60155 

708-338-3806 

Cook 

Sertoma Centre, Inc 

4343 West 123rd Street 

Alsip, IL 60803 

708-371- 9700 

Cook 

Southwest Community Services, Inc 

6775 Prosperi Drive 

Tinley Park, IL 60477 

708-429-1260 

Cook 

Stickney Public Health District 

5635 State Road 

Burbank, IL 60459 

847-570-2540 

Cook 

The Camelot Schools 


Suite 300 Quigley 


847-391-8000 

Cook 

The Kenneth Young Centers 

1001 Rohlwing Road 

Elk Grove Village, IL 60007 

847-524-8800 

Cook 

Thresholds 

2700 North Lakeview 


773-537-3215 

Cook 

Pilsen- Little Village Community Mental 

Health Center 

2319 South Damen Avenue 


773-579-0832 

Cook 

Riveredge Hospital 

8311 West Roosevelt Road 

Forest Park, IL 60130 

708-209-4181 

Cook 

South Central Community Services, Inc 

8316 South Ellis Avenue 


773-483-0900 

Cook 

St Mary of Nazareth Hospital 

2233 West Division Street 


312-770-2000 

Cook 

Streamwood Behavioral Health Center 

1400 East Irving Park Road 


630-837-9000 

Cook 

The Day School 

800 West Buena Avenue 


773-327-6000 

Cook 

The Youth Campus 

733 North Prospect Avenue 

Park Ridge, IL 60068 

847-823-5161 

Cook 

Trilogy 

1400 West Greenleaf Avenue 


773-508-6100 



Cook 

Turning Point 

8324 Skokie Boulevard 

Skokie, IL 60077 

847-933-0051 

Cook 

UIC Department of Psychiatry 

912 South Wood Street (MIC 913) 



Cook 

WillPower, Inc 

444 Frontage Road 

Northfield, IL 60093 

847-501-4718 

Crawford 

SE Illinois Counseling Centers 

204 West Highland 

Robinson, IL 62454 

618-546-1021 

Dekalb 

Ben Gordon Community 

Mental Health Center 

12 Health Service Drive 

DeKalb, IL 60115 

815-756-4875 

Douglas 

Douglas County Mental Health 

114 West Houghton 

Tuscola, IL 61953 

217-253-4731 

Edgar and Clark County 

Edgar Human Resources Center 

753 East Court, P.O. Box 1118 

Paris, IL 61944 

217-465-4118 

Effingham 

Heartland Human Services and 

Counseling Center 

1200 North 4 th Street, P.O. Box 1047 

Effingham, IL 62401 

217-347-7179 

Cook 

Uhlich Children Advantage Network 

3737 North Mozart 


773-588-0180 

Cook 

Victor C Neumann Association 

5547 North Ravenswood Avenue 


773-769-4313 

Cook 

Youth Guidance 

122 South Michigan Avenue 

Suite 1510 


312-253-4900 

Cumberland 

Cumberland Associates 

120 Courthouse Square, P.O. Box 385 

Toledo, IL 62468 

217-849-3803 

DeWitt 

DeWitt County Human Resources 

1150 Route 54 West 

Clinton, IL 61727 

217-935-9496 

DuPage 

DuPage County Health Department 

Mental Health Division 

111 North County Farm Road 

Wheaton, IL 60187 

630-682-7400 

Edwards 

SE Counseling Center 

254 South 5 th 

Albion, IL 62806 

618-445-3559 

Fayette 


421 West Main 

Vandalia, IL 62471 

618-283-4229 



Ford 

Community Resources and 


1510 West Ottawa Road, P.O. Box 162 

Paxton, IL 60957 

217-379-4302 

Fulton 


229 Martin Avenue 

Canton, IL 61520 

309-647-1881 

Greene 

Tri County Counseling Center 

220 East County Road 

P.O. Box 381 


618-498-9587 

Hamilton 

Jefferson County Comprehensive 

Services 

Route 14 East 

McLeansboro, IL 62859 

618-643-3103 

Hardin 

Family Counseling Center, Inc 

212 Main Street 

Elizabethtown, IL 62931 

618-287-7010 

Henry 

Bridgeway, Inc 

137 East College 

Kewanee, IL 61443 

309-852-4331 

Jackson 

Southern Illinois Regional 

Social Services 

604 East College Street 

Carbondale, IL 62901 

618-457-6703 

Jefferson 


Service 

Route 37 North, P.O. Box 428 

Mt. Vernon, IL 62864 

618-242-1511 

Franklin 

Franklin-Williamson Human Services 

902 West Main Street 

West Frankfort, IL 62896 

618-937-6483 

Gallatin 

Egyptian Public Health Department 

Box 181 Main Street 

Ridgeway, IL 62979 

618-272-4691 

Grundy 

Grundy County Health Department 

1320 Union 

Morris, IL 60450 

815-941-3138 

Hancock 

Mental Health Center of Western IL 

607 Buchanan Street 

Carthage, IL 62321 

217-357-3176 

Henderson 


Hwy 164 West Access Road 

Oquawka, IL 61469 

309-867-2626 

Iroquois 

Iroquois Mental Health Center 

323 West Mulberry Street 

Watseka, IL 60970 

815-432-5241 

Jasper 

Jasper County Health Department 

Division of Counseling Services 

106 East Edwards 

Newton, IL 62448 

618-783-4154 

Jersey Tri-County Counseling 

220 East County Road 

P.O. Box 381 

Jersey ville, IL 62052 

618-498-9587 



Jo Daviess 

FHN Family Counseling Center 

300 Summit 

Galena, IL 61036 

815-777- 2836 

Kane 

Association for Individual Development 

309 West New Indian Trail Court 

Aurora, IL 60506 

630-844-5040 

Kane 

Family Service Association 

of Greater Elgin Area 

22 South Spring Street 

Elgin, IL 60120 

847-695-3680 

Kane 

TriCity Family Services 

1120 Randall Court 

Geneva, IL 60134 

630-232-1070 

Kankakee 

Helen Wheeler Center C.M.H. 

275 East Court Street, Suite 102 

Kankakee, IL 60901 

815-939-3543 

Kendall See Kane 

Lake 

Independence Center 

2025 Washington Street 

Waukegan, IL 60085 

847-360-1020 

Lake 

Lake County Behavioral Health 

(Children) 

3012 Grand Avenue 


847-360-3160 

Johnson 

Family Counseling Center 

408 Vine Street 

Vienna, IL 62995 

618-658-2611 

Kane 

Ecker Center 

1845 Grandstand Place 


847-695-0484 

Kane 

Larkin Center 

1212 Larkin Avenue 


847-695-5656 

Kankakee 

Grow in Illinois 

1108 East Court Street 


815-933-6690 

Kankakee 

Indian Oaks Academy 

101 Bramble Street, 

Manteno, IL 60950 

815-802-3700 

Knox 

Bridgeway 

2323 Windish Drive 

Galesburg, IL 61401 

309-344-2323 

Lake 

Lake County Behavioral Health (Adults) 



847-360-6725 

Lake Northpointe Resources, Inc 

3441 Sheridan 

Zion, IL 60099 

847-872-1700 



LaSalle 


2960 Charters Street 

P.O. Box 1488 

LaSalle, IL 61301 

815-223-0160 

Lawrence 

South East Counselling Center 

1501 Olive 

Lawrenceville, IL 62439 

618-943-3451 

Livingston 

Institute for Human Resources 

P.O. Box 768 

310 East Torrance Avenue 

Pontiac, IL 61764 

815-844-6109 

Macon 

Heritage Behavioral Health Center 

151 North Main Street 

Decatur, IL 62525 

217-362-6262 

Madison 

Behavioral Health Alternatives, Inc 

337 East Ferguson Avenue 

Wood River, IL 62095 

618-251-4073 

Madison 

Community Counseling Center of North 

Madison County 

2615 Edwards Street 

Alton, IL 62002 

618-462-2331 

Marshall (See Bureau) 

Marion 


101 South Locust 

Centralia, IL 62801 

618-533-1391 

Lawrence 

Lawrence County Health Department 

Route #3, Box 414 


618-943-3754 

Lee 

Sinnissippi Centers 

325 Illinois, Route 2 

Dixon, IL 61021-9162 

815-284-6611 

Logan 

Mental Health Centers of Central IL 

304 8 th Street 

Lincoln, IL 62656 

217-735-2272 

Macoupin 

Locust Street Resource Center 

320 South Locust 

Carlinville, IL 62626 

217-854-3166 

Madison 

Chestnut Health System 

50 Northgate Industrial Drive 

Granite City, IL 62040 

618-877-4420 

Madison 

Residential Options, Inc 

4452 Industrial Drive 


618-466-1803 

Mason (See Sangamon) 

Massac 

Massac County Mental Health and 

Family Counseling 

206 West 5th Street 

Metropolis, IL 62960 

618-524-9368 



McDonough 


900 South Deer Road 

Macomb, IL 61455 

309-837-4876 

McHenry 

Family Alliance, Inc. 

2028 North Seminary Avenue 

Woodstock, IL 60098 

815-338-3590 

McHenry 

Pioneer Center for Human Services 

4001 Dayton Street 

McHenry, IL 60050 

815-344-1230 

Menard (See Sangamon) 

Monroe 

Human Support Services 

988 North Market 

Waterloo, IL 62298-1000 

618-939-8644 

Morgan 

Mental Health Centers of Central IL 

340 West State, P.O Box 370 

Jacksonville, IL 62651 

217-245-6126 

McDonough 


System 

301 E Jefferson 


309-833-2191 

McHenry 

Family Service and Community Mental 

Health Center for McHenry County 

4100 Veterans Parkway 


815-385-6400 

McLean 

McLean County Center for 

Human Services 

108 West Market 

Bloomington, IL 61701 

309-827-5351 

Mercer (See Rock Island) 

Montgomery 

Montgomery County Health 

Department 

11191 IL RTE 185 

Hillsboro, IL 62049 


Moultrie 

Moultrie County Counseling Center 

12 West Harrison Street 

Sullivan, IL 61951 

217-728-4358 

Ogle (See Lee) Peoria 

Children’s Home Association of Illinois 

2130 North Knoxville 

Peoria, IL 61603 

Peoria 

Community Workshop and Training 

Center 

3215 North University Street 


309-686-3300 

309-685-1047 

Peoria 

South Side Office of Concern 

1316 South West Adams 


309-674-7310 



Peoria 

Human Services Center 

228 Northeast Jefferson 


309-671-8000 

Perry 

Perry County Counseling Center 

1016 South Madison Street, Suite A 

DuQuoin, IL 62832 

618-542-4357 

Pope 

Family Counseling Center 

125 North Market Street 

Golconda, IL 62938 

618-683-2461 

Piatt 

Piatt County Mental Health Center 


Monticello, IL 61856 

217-762-5371 

Pike 

Mental Health Centers of Western 

Illinois of Pike County 

121 South Madison 

Pittsfield, IL 62363 

217-285-4436 

Pulaski (See Alexander) 

Putnam (See Bureau) Randolph 

Human Services Center of Southern 

Metro East 

10257 State Route 3 

Red Bud, IL 62278 

Richland 

Southeastern Illinois Counseling 

Center, Inc. 

504 Micah Drive, Drawer M 

Olney, IL 62450 

618-395-4306 

Rock Island 

Transitions, N.F.P. 

805 19 th Street, P.O. Box 4238 

Rock Island, IL 61204 

309-793-4993 

St. Clair 

Comprehensive Mental Health Center 

of St. Clair County 

3911 State Street 

East St. Louis, IL 62205 

618-482-7330 

Sangamon 

SIU School of Medicine 

Department of Psychiatry 

901 West Jefferson, P.O. Box 19642 

Springfield, IL 62794 

217-545-8229 

618-282-6233 

Rock Island 

Robert Young Center for Community 

Mental Health 

4600 3 rd Street 

Moline, IL 61265 

309-779-2031 

St. Clair 

Call for Help, Inc. 

9400 Lebanon Road 

Edgemont, IL 62203 

618-397-0968 

Sangamon 

Mental Health Centers of 

Central Illinois 

710 North 8th Street 


217-525-1064 

Schuyler 

Schuyler County Mental Health 

127 South Liberty 

Rushville, IL 62681 

217-322-4373 



Saline 

Egyptian Public and Mental Health 

Department 

1412 US 45 North 

Eldorado, IL 62930 

618-273-3326 

Shelby 

Shelby County Community Services 

1810 West South 3rd Street 

P.O. Box 650 

Shelbyville, IL 62565 

217-774-2113 

Stephenson 

FHN Family Counseling Center. 

421 West Exchange Street 

Freeport, IL 61032 

815-599-7300 

Union 

Union County Counseling Service 

204 South Street, P.O. Box 548 

Anna, IL 62906 

618-833-8551 

Vermilion 

Crosspoint Human Services 

210 Avenue C 

Danville, IL 61832 


Wabash 

SE Illinois Counseling Center 

602 East 5 th Street 

Mt Carmel, IL 62863 

618-262-7473 

Washington 

Washington County Counseling 

781 East Holzhauer Drive, 

P.O. Box 273 

Nashville, IL 62263 

618-327-3348 

White 

Egyptian Public Mental Health 

1705 College Avenue 

Carmi, IL 62821 

618-382-7311 

Scott (See Morgan) 

Stark (See Bureau) 

Tazewell 

Tazwood Mental Health Center 

3248 Vandever Avenue 

Pekin, IL 61554 

309-347-5579 

Vermilion 

Center for Children’s Services 

702 North Logan Avenue 


217-446-1300 

Wabash 

Wabash County Health Department 


Mt. Carmel, IL 62863 

618-263-3873 

Warren 


301 Industry Park Road 

Monmouth, IL 61462 

309-734-9461 

Wayne 

SE Illinois Counseling Center 

407 North Basin, Route 3, Box 770 

Fairfield, IL 62837 

618-842-2125 

Whiteside 

Sinnissippi Centers, Inc 

2611 Woodlawn Road 

Sterling, IL 61081 

815-625-0013 



Will 

Cornerstone Services, Inc 

777 Joyce Road 

Joliet, IL 60436 

815-727-6666 

Will 

Will County Health Department 

501 Ella Avenue 


815-727-8521 

Winnebago 

Janet Wattles Mental Health Center 

526 West State Street 

Rockford, IL 61101 

815-968-9300 

Winnebago 

Stepping Stones of Rockford 



815-963-0683 

Will 

Trinity Services, Inc 

100 North Cougar Road 


815-485-6197 

Williamson 

Illinois Center for Behavioral Health 

Franklin- Williamson County Human 

Services 

3111 Williamson Parkway 

Marion, IL 62959 

618-997-3647 

Winnebago 

Mildred Berry Center 

8616 Northern Avenue 


815-332-8003 

Woodford 

Tazwood Mental Health Center 

109 East Eureka Street 

Eureka, IL 61530 

309-467-3770 



Appendix 4 

HEALTHY KIDS 

Substance Abuse Screening and Referral Resources 

SUBSTANCE ABUSE SCREEN INSTRUCTIONS 

The screen can be administered by virtually anyone who knows the patient, like the 

parent or another significant person in the patient’s life; or a person who has a 

professional relationship with the patient, such as a nurse or other physician’s office 

personnel. The screen is NOT a diagnostic tool. Rather it provides a way to 

capture some vital information that can be used to either confirm, or dispel, the 

possibility of a substance abuse problem with the young person under 

consideration. 

With the exception of the items in bold print, no single response has much meaning in, 

and of, itself. It is a series of responses that present a pattern, no matter how slight, of 

attitudes and behaviors, which lead the screener to feel that more information is 

needed. The screening process will not confirm the existence of a substance abuse 

problem, but it will give sufficient support for a recommendation that the client see a 

substance abuse professional for a formal, clinical evaluation. 

It is important for the screener to remember that the earlier a problem is identified, the 

earlier a serious intervention can begin. Substance abuse that is caught early is very 

treatable. Like most diseases, however, if left untreated, the costs, both personal and 

financial, grow considerably. 

Guidelines to Each Section 

Thinking: How the patient processes information is the focus of this section. Everyone 

will get confused at times and at times, forget things. That is normal. What is being 

assessed is a pattern of thought processes that are significantly different from other 

young people. In other words, does the patient usually process information normally, or 

is he/she usually confused, distracted, and disoriented? 

Life Style Changes: No single item means a problem in isolation. If a pattern of 

responses is noted however, the screener should begin to consider the possibility of 

dysfunctional living. Combinations of these elements present a set of characteristics 

that are common to many youthful substance abusers. 

Temperament: There is no need to be concerned with the occasional or sporadic flash 

of temper. All young people get frustrated from time to time and that frustration often 

takes the form of anger or a negative attitude. In this section, the screener is trying to 

find out if the young person shows these negative behaviors or attitudes represent a 

change from the way the patient used to be. Many times this will be noted when a 

parent says something like “I just don’t know what’s the matter with him/her anymore. 

He/She used to be such a nice boy/girl.” 

Social: This is the area that the patient and the family often have the hardest time 

talking about. Many things influence the environment in which the patient lives. If those 

environmental factors reflect negatively on the parents, they do not surface easily. For 

example, if the parents are problem drinkers, or if they do drugs themselves, it will be 

difficult for them to admit that their behavior has a negative impact on the rest of the 



family. Also, as young people mature, their peer relationships change. This is normal. 

However, if the young patient now rejects, or is rejected by the friends he/she once had 

and if the new friends tend to be secretive or reluctant to share what they do with 

others, especially with adults, it might indicate that the patient’s new constellation of 

friends belong to the marginal sub-culture associated with drug use. With young 

people, the old adage that, “you are known by the friends you keep,” is very accurate. 

Again, in this section, the screener is looking for abrupt change and for patterns of signs 

and symptoms. Any one of the items by itself has little, if any, significance. 

Behavior: This section deals with elements that are the most obvious, and the 

behaviors noted here are the ones most commonly associated with a young person who 

is attempting to deal with a problem of some type. Those attempts may, or may not, 

involve drug use. Or, drug use itself may be the problem. Finding out, which came first 

is not important at this point. The important thing is to note that all of these behaviors 

tend to be negative and a pattern of even a couple of them is an excellent indicator that 

some kind of professional involvement is called for. If drug use can be ruled out early, 

other appropriate help can be provided. If the professional finds substance abuse at 

this early stage, however, a lot of critical time has been saved and the appropriate 

treatment can begin sooner, rather than later. 

Substance Abuse: Any checked item in this section is an automatic “trigger” to make a 

referral for a formal, clinical assessment by a substance abuse professional. If the 

screener notes even one of these examples, the case should be referred for 

professional interventions. In conclusion, the screener can either write up a brief 

summary for the physician, or the completed screen can simply be given, without 

comment, to the doctor for evaluation. In any event, the physician will determine the 

next step in the patient’s care. If a referral is made, the Primary Care Provider, or case 

manager, if the patient has been assigned one, should see to it that the patient keeps 

the appointment for a clinical assessment by the substance abuse professional. 

INSTRUCTIONS 

SUBSTANCE ABUSE PRE-ASSESSMENT SCREEN 

Use and Referral Process 

To make a referral for clinical assessment of a suspected problem with alcohol or other 

drug abuse, please administer the attached pre-assessment screen to the patient. The 

screen is in a simple checklist format and it can be administered by virtually anyone. 

When the screen has been completed, review the results. If, in the provider’s 

professional opinion, there is reason to SUSPECT the presence of a substance abuse 

problem, refer that patient to a substance abuse professional for a clinical assessment. 

Once completed, that assessment will be returned to the provider for inclusion in the 

provider’s comprehensive evaluation of the patient and patient’s confidential medical 

record. 



DECISION-MAKING REGARDING SUBSTANCE ABUSE REFERRALS 

Sorting Out the Levels of Risk 

Referrals under the EPSDT program requires that the physician/provider: 

• Obtain written consent of the patient to release information to the substance 

abuse treatment provider 

• Make contact with an approved substance abuse treatment services provider 

to arrange an appointment 

• Communicate with the patient and parent, the appointment time and location 

before they leave the provider’s office following the screening 

• Send copies of your Substance Abuse Treatment Screen to the referral 

source 

• Receive from the referral source within a reasonable amount of time (e.g. ten 

days following the appointment date) notification as to the disposition 

(show/no show) of the appointment, including any diagnosis and 

recommendations 

The substance abuse treatment provider will, with the written permission of the parent: 

• Receive the referral 

• Notify the physician if the appointment was not kept and has been rescheduled. 

If the patient has an identified case manager, the case manager 

should be notified for the purpose of follow-up. 

• Assess the patient 

• Provide continuing feedback to the referring physician as indicated (e.g. 

significant changes in the treatment plans) 

CONTACT POINTS FOR SUBSTANCE ABUSE TREATMENT SERVICES 

To arrange for a pre-assessment screening to identify the presence of a substance 

abuse problem, or to schedule a formal, clinical assessment of your patient by a 

certified substance abuse professional, please contact an appropriate agency or 

program. 

The Substance Abuse Screening Instrument (HFS 3411D) can be ordered by providers 

from the HFS Warehouse: 

2946 Old Rochester Road 

Springfield, IL 62703-5659 

All requests must be received on the HFS 1517 (R-9-06). This form may be obtained 

from HFS’ Web site or email address: http://www.hfs.illinois.gov/forms/ 

The form may be faxed to (217) 557-6800. 

Additional information about ordering Department forms can be found in Chapter 100 - 

General Policy and Procedures, 112.43 Ordering of Claims Forms and Envelopes. 





Appendix 4 

I. PATIENT 

HEALTHY KIDS SUBSTANCE ABUSE SCREEN 

Illinois Department of Healthcare and Family Services 

Bureau of Maternal and Child Health Promotion 

NAME: ____________________________________________ MEDICAID NUMBER_______________ 

BIRTH DATE: ______________________________ AGE_____________ GRADE__________________ 

II. PARENT III. SCREENER 

NAME:_____________________________ NAME:______________________ 

ADDRESS_____________________________________ PHYSICIAN/CLINIC__________________ 

PHONE _______________________________________ 

ADDRESS/PHONE___________________ 

INSTRUCTIONS: Question the patient and parent. Check any items listed below 

which pertain to the patient. Make a referral for a Substance Abuse Assessment 

when necessary. ANY BOLDED ITEMS CHECKED BELOW REQUIRE AN 

IMMEDIATE REFERRAL. (Refer to the attached instructions.) STOP! If the 

patient has already been referred or is currently receiving treatment for 

substance abuse, do not continue. 



THINKING 

___Frequent Memory Loss 

___Confusion 

___Easily Distracted 

___Difficulty Concentrating 

LIFE STYLE CHANGES 

___Change in Group of Friends 

___Poor Personal Hygiene 

___Unkempt Appearance 

___Drug Oriented Language 

___Erratic Sleep Patterns 

___Poor Eating Habits 

___Unfulfilled Promises 

___Excessive Interest in “Hard 

Rock” Music (Heavy Metal, 

Acid) 

___Cult Activities 

___Involvement in Gang or 

Gang Activity 

TEMPERAMENT 

___Overly Defensive 

___Quick to anger 

___Listless, Uninterested 

___Argumentative 

___Cocky, Arrogant 

___“Spaced Out” Much of the 

Time 

HFS 3411D (N-5-93) 

SOCIAL 

___Problems at Home 

___Substance Abuse at Home 

___Problems with Neighbors 

___Loss of Former Friends 

___School Problems 

___Disliked by Significant Other 

___Evidence Peers are Drug 

Involved 

___Evidence of Low Self-Esteem 

BEHAVIOR 

___Increase in Secretive Behavior 

___Cruel (Hurts Others) 

___Self Hurt (Mutilation, Tattoos) 

___Hurts Animals 

___Over Reacts/Under Reacts 

___Defiant of Authority 

___Excuses, Lies 

___Suicidal, Ideation of Attempt 

___Avoidance of Parents, Family 

Members, Authority Figures, 

Adults 

___Severe Mood Swings 

SUBSTANCE ABUSE 

___Obviously Intoxicated at Times 

___Possession of Drug Paraphernalia 

___“Glassy” Eyes 

___Blackouts 

___Signs of IV Drug Use 

___Signs of Nasal Damage from 

Inhalation, Sniffing or “Snorting” 

___Other Evidence of Drug Use 



PSYCHIATRIC HOSPITALIZATION during the past three years___patient____family 

member 

SUBSTANCE ABUSE TREATMENT during the past three years____ patient ___family 

member. 

List other MEDICAL CONDITIONS that may impact social or emotional development. 

Is the patient currently on MEDICATION? If so, specify medications and dosages: 

COMMENTS (Substance Abuse): 

________CHECK IF PARENT REQUESTS A REFERRAL. 

Suspected Child ABUSE and NEGLECT must be reported to DCFS 

immediately! 

1-800-25ABUSE. 

The PHYSICIAN conducting the Healthy Kids Substance Abuse Screen: 

• Makes an appointment with a substance abuse treatment provider when 

indicated while the patient is at your office and the information about the 

appointment should be given to the parent 

• Sends a copy of this form to the substance abuse treatment provider 

REFERRAL TO______________________________________________________ 

DATE ________________________TIME_________________________________ 

DATE CLIENT NOTIFIED OF APPOINTMENT_____________________________ 

BY WHOM_________________________________________________________ 

The SUBSTANCE ABUSE PROVIDER conducting the substance abuse 

assessment, with the signed consent of the parent: 

� Sends a copy of this form to the referring physician once the assessment 

has been completed indicating recommended services 

� Informs the referring physician of the missed or rescheduled 

appointments 

� Reports the patient’s progress or change in treatment plans on a 

quarterly basis until case closure 



To be completed by the SUBSTANCE ABUSE PROVIDER ONLY and returned to the 

referring physician. 

DATE OF ASSESSMENT__________________ 

DIAGNOSIS_________________________ 

RECOMMENDED SERVICES: 



Appendix 4 

Adams 

Adams County Juvenile Detention 

Center/Great River Recovery Resources 

200 North 52nd Street 


217-277-2233 

Alexander 

Community Health and Emergency 

Services, Inc (CHESI) 

13245 Kessler Road, P.O. Box 233 


618-734-4400 

Alexander 

Delta Center, Inc. 

1701 Washington Avenue 


618-734-9770 

Boone 

P.H.A.S.E., Inc. 

2028 North State Street, Suite 200 

Belvidere, IL 61008 

815-547-4502 

Carroll 

Sinnissippi Centers, Inc. 

1122 Healthcare Drive 

Mount Carroll, IL 61053 

815-244-1376 

Champaign 

Prairie Center - Champaign 

122 West Hill Sreet, P.O. Box 1397 


217-356-7576 

Champaign 

Prairie Center Health Systems, Inc. 

Urbana 

718 Killarney Street 


217-328-4500 

Illinois Department of Human Services 

Division of Alcoholism and Substance Abuse 

Certified Medicaid Providers by County 

Adams 

Great River Recovery Resources, Inc 

428 South 36th Street 


217-224-6300 

Alexander 

Delta Center, Inc 

1400 Commercial Avenue 


618-734-2665 

Bond 

Bond County Health Department 

503 South Prairie Street 

Greenville, IL 62246 

618-664-1442 

Bureau 


Systems, Inc 

526 Bureau Valley Parkway, Perry Plaza 

Princeton, IL 62356 

815-875-4458 

Cass 

Cass County Mental Health Association 

121 East Second Street 

Beardstown, IL 62618 

217-323-2980 

Champaign 

Alcohol / Chemical Evaluation Services, 

Dba A.C.E.S., Ltd. 

217 North Broadway Avenue 


217-352-9122 

Christian 

Triangle Center 

320 Northwestern Avenue 

Taylorville, IL 62568 

217-824-7330 



Clark 

Human Resources Center of Edgar and 


1006 South 6 th Sreet 

Marshall, IL 62441 

217-826-6212 

Clay 

Southeastern/ Clay Family Counseling 

Center 



618-662-2871 

Coles 

C.E.A.D. Council 

1501 1/2 18th Street 

Charleston, IL 61920 

217-348-5444 

Coles 

C.E.A.D. Council/DASA-DCFS Initiative 

Program 

726 4th Street 


217-348-8591 

Coles 




217-258-2968 

Cook (Chicago) 

Addiction Counseling Educational 

Services (ACES) Catholic Charities 

651 West Lake Street, Suite 100 


312-655-7453 


Alternatives, Inc. 

4730 North Sheridan Road 


773-506-7474 


Anixter Center/Schwab Rehabilitation 

Center 

1414 South Fairfield Avenue 


773-522-2010 

Clay 

Clay Family Counselling Center 



618-662-2871 

Clinton 


580 8 th Sreet 

Carlyle, IL 62231 

618-594-4581 

Coles 


635 Division Street, P.O. Box 532 


217-348-8108 

Coles 


8500 East County Road 150N 

Lerna, IL 62440 

217-235-1303 

Coles 

C.E.A.D. Council Adolescent Outpatient 



217-258-6018 


Alcohol And Drug Assessment Services 

651 West Lake Street, Rm. 100A 


312-655-7530 


Anixter Center - Outpatient Services 

2001 North Clybourn, Suite 402 


773-549-0208 


Anixter Center-Inpatient Services 

1706 North Kedzie 


773-227-8530 




Association House Of Chicago 



773-772-8009 


Brass II 

8000 South Racine Avenue 


773-994-2708 


Cathedral Shelter Of Chicago 

Adult Outpatient Program 

1668 West Ogden Avenue 


312-997-2222 


Community Counseling Centers of 

Chicago 

4740 North Clark Street 


773-769-0205 


Counseling Center of Lake View 

3225 North Sheffield Avenue 


773-549-5886 


ERIE Family Health Center/West Town 

1701 West Superior Avenue 


312-666-3488 


Family Guidance Centers, Inc. 

3800 West Madison Avenue 


773-638-2849 


Garfield Counseling Center 

Full Service Program 

4132 West Madison Street 


773-533-0433 


Bobby E. Wright Comprehensive 

Community Mental Health Center, Inc. 

9 South Kedzie Avenue 


773-722-7900 


Caritas - Central Intake 

140 North Ashland Avenue, Suite 100 


312-850-9411 


Community Counseling Centers of 

Chicago - Recovery Point 

4007 North Broadway Avenue 


773-305-1101 


Cornell Interventions Southwood 

5701 South Wood Street, 3rd Fl. North 


773-737-4600 


El Rincon Clinic 

1874 North Milwaukee Avenue 





310 West Chicago Avenue 


312-943-6545 


Fola Community Action Services, Inc. 

8014 South Ashland Avenue 


773-487-4310 


Gateway Foundation 

Chicago Outpatient Northwest 



773-862-2279 





Westside Treatment Center 

3828 West Taylor Street, 1 st Floor 

Main Center 


773-826-1916 


H.R.D.I. Adolescent and 

Family Life Program 

2311 East 98th Street 


773-933-5570 


Habilitative Systems - Alcoholism and 

Chemical Abuse 

South Outpatient Services 

6857 South Halsted Street 


773-854-1812 


Harbor Light Alcoholism and Drug 

Dependence Services 

1515 West Monroe Street 


312-421-5753 


Haymarket Center - O'hare Outreach 

O'hare International Airport 

P.O. Box 66243 


773-686-6480 


Healthcare Alternative Systems, Inc. 

5005 West Fullerton Avenue 


773-745-7107 


Heartland Health Outreach Pathways 

Home Outpatient 

4750 North Sheridan Road, Suite 500 


773-334-7117 


H.R.D.I. - Harriet Tubman 

Women and Children Residential 

11352 South State Street 


773-785-4955 


H.R.D.I. West Pullman Professional 

Counseling Services 

33 East 114th 


773-660-4630 


Habilitative Systems, Inc. 

415 South Kilpatrick Street 


773-261-2252 


Haymarket Center 

108 North Sangamon Street 


312-226-7984 



2755 West Armitage Avenue 


773-252-3100 



Adult Residence 

1949 North Humboldt Boulevard 


773-252-2666 


Heartland Human Care Services, Inc. 

Rafael Center 

4411 North Ravenswood Avenue, 3rd Fl. 


773-751-4000 




HRDI - Grand Boulevard Professional 


340 East 51st Street 


773-869-0300 


Komed/Holman Health Center 

4259 South Berkeley 


773-268-7600 


Loretto Hospital Addictions Center 

645 South Central Avenue, 8th Fl 


773-626-9250 


LSSI - Belmont 

5825 West Belmont Avenue 


773-637-0487 


LSSI - Devon II 

1764 West Devon Avenue 


773-764-4512 


LSSI - Mt. Greenwood 



773-881-1900 


Near North Health Services Corporation 

1276 North Clybourn 


312-337-1073 


Nuway Community Services, Inc. 



773-723-2790 

Cook(Chicago) 

Intervention Instruction, Inc 

2001 West Addison Street 


773-248-6628 


Latino Treatment Center 

2608 West Peterson Avenue, 5 th Fl 

Suite 505 


773-465-1161 


Louise Landau Health Center 

Near North Health Services, Inc. 

3645 West Chicago Avenue 


773-826-3450 


LSSI - Devon I 

1758 West Devon Avenue 


773-764-4350 


LSSI - Kenmore Outpatient 

5517 North Kenmore Avenue,1st Floor 


773-275-7962 


Mercy Hospital and Medical Center 

2525 South Michigan Avenue, 4 th Floor 


312-567-2295 


New Age Services Corporation 

1330 South Kostner Avenue 


773-542-1150 


PDSSC - Chicago, Inc. 

2260 North Elston Avenue 


773-772-2450 




Pilsen-Little Village 

Methadone Substance Abuse Division 



773-277-3413 


South East Alcohol and Drug Abuse 

Center 

8640 South Chicago Avenue 


773-731-9100 


The Mcdermott/Haymarket Center 

Haymarket Grand Boulevard 

4910 South King Drive 


773-548-7598 


The Women's Treatment Center 

140 North Ashland Avenue 

3rd Fl. East 


312-633-4951 


Woodlawn Organization Entry House 



773-493-6116 


Youth Outreach Services 

5910 West Division 


773-379-3600 





773-478-4500 

Cook (Suburb) 

YMCA of Metropolitan Chicago 

Southwest YMCA 


Alsip, IL 60803 

708-385-6700 


Procare Centers in Our Lady of 

Resurrection Medical Center 

5645 West Addison 


773-282-7000 


Substance Abuse Services, Inc. 

Outpatient Unit 

2101 South Indiana Avenue 


312-808-3210 


The Mcdermott Center/ 

Haymarket Center North 

4753 North Broadway, Suite 612 


773-506-2839 


The Women's Treatment Center 

140 North Ashland Avenue, 1st Floor 


312-850-0050 


Westside Holistic Family Center/ 

Ujima House 



773-921-8777 



5114 South Elizabeth Street 


773-446-6244 



6417 West Irving Park Road 


773-777-6377 

Cook (Suburb) 

OMNI Youth Services 

Arlington Heights Office 

1616 North Arlington Heights Road 

Arlington Heights, IL 60004 

847-253-6010 



Cook (Suburb) 

Procare Centers 

Judicial Treatment/Intake 



708-681-2324 

Cook (Suburb) 


Buffalo Grove Office 

1111 West Lake Cook Road 

Buffalo Grove, IL 60089 

847-353-1500 

Cook (Suburb) 



Cicero, IL 60804 

708-652-5370 

Cook (Suburb) 

Maryville Academy/Mulcahey 


100-300 Mulcahey Bld 


847-294-1999 

Cook (Suburb) 

SSCASA - Addicted Mother's 

Residential Rehabilitation Program 

1909 Checker Square 

East Hazel Crest, IL 60429 

708-647-3333 

Cook (Suburb) 

Renz Addiction Counseling Center 

Two American Way 


847-742-3545 

Cook (Suburb) 

Leyden Family Service and 

Mental Health Center 


Franklin Park, IL 60131 

847-451-0330 

Cook (Suburb) 


15400 Page Avenue 

Harvey, IL 60426 

708-333-8960 

Cook (Suburb) 

Resurrection Behavioral Health 

St. Elizabeth Hospital 



708-410-0615 

Cook (Suburb) 

Aunt Martha’s Outpatient Youth 

Enhancement 

1526 Otto Boulevard 

Chicago Heights, IL 60411 

708-754-1044 

Cook (Suburb) 

Family Guidance Center 

484 Lee Street 


847-827-7517 

Cook (Suburb) 

Maryville Academy 

Scott Nolan Center 

555 Wilson Lane 


847-768-5430 

Cook (Suburb) 

LSSI - Elgin Center I Residential 

675 Varsity Drive 


847-741-2600 

Cook (Suburb) 

Peer Services, Inc. 

906 Davis Street 


847-492-1778 

Cook (Suburb) 

Peer Services, Inc. 

3633 West Lake Avenue, Suite 305 

Glenview, IL 60026 

847-657-7337 

Cook (Suburb) 



Hickory Hills, IL 60457 

708-741-4500 



Cook (Suburb) 

The Share Program 

1776 Moon Lake Blvd. 

Hoffman Estates, IL 60194 

847-882-4181 

Cook (Suburb) 

Substance Abuse Operations 

308 South 5th Avenue 

Maywood, IL 60153 

708-343-1275 

Cook (Suburb) 

Pilsen-Little Village Community Mental 

Health Center, Inc. 

1633 North 37th Avenue 

Melrose Park, IL 60160 

708-343-7860 

Cook (Suburb) 


4419 West North Avenue 


708-547-1091 

Cook (Suburb) 

The Way Back Inn 

412 South Wesley 


708-848-2065 

Cook (Suburb) 

Comgraph, Inc. 


Park Forest, IL 60466 

708-481-9570 

Cook (Suburb) 

Haymarket West 

1990 East Algonquin Road, Suite 211 

Schaumburg, IL 60173 

847-397-7291 

Cook (Suburb) 

Renz Addiction Counseling Center 

1535 Burgundy Parkway 


630-837-6445 

Cook (Suburb) 


333 North La Grange Road 

La Grange Park, IL 60526 

708-698-5500 

Cook (Suburb) 

The Way Back Inn 

201 South 2nd Avenue 

Maywood, IL 60153 

708-345-8422 

Cook (Suburb) 

Resurrection Behavioral Health 



708-681-0073 

Cook (Suburb) 

Bremen Youth Services 

15350 Oak Park Avenue, P.O. Box 627 

Oak Forest, IL 60452 


Cook (Suburb) 

Aunt Martha's Youth Service Center, Inc. 

440 Forest Blvd. 

Park Forest, IL 60466 

708-679-8000 

Cook (Suburb) 

Intervention Instruction, Inc. 

2121 Euclid Street 

Rolling Meadows, IL 60008 

847-818-2885 

Cook Suburb) 

Pilsen Little Village Community Mental 

Health Center, Inc. 

1546 North Mannheim Road 

Stone Park, IL 60165 

708-410-0856 

Cook (Suburb) 

Streamwood Behavioral Health Center 

1400 East Irving Park Road 


630-837-9000 



Cook (Suburb) 

OMNI Youth Services, Inc. 

Wheeling Township Program 

210 North Wolf Road 

Wheeling, IL 60090 

847-541-0199 


Southeastern/ Crawford Family 

Counseling Centers 

204 West Highland Avenue 


618-546-1021 

Dewitt 

Dewitt County Human Resource Center 

1150 Route 54 West Box 616 

Clinton, IL 61727 

217-935-9496 

DuPage 

Bensenville Home Society 

331 South York Road 

Bensenville, IL 60106 

630-766-3570 

DuPage 

Elmhurst Memorial Hospital 

Guidance Services 

183 North York Road 

Elmhurst, IL 60126 

630-941-4577 

DuPage 

Cornell Interventions DuPage 

Adolescent Center 

11 South 250, Rt. 83 

Hinsdale, IL 60521 

630-325-5050 

DuPage 

Behavioral Health Services of Central 

DuPage Hospital 

27 West 350 High Lake Road 

Winfield, IL 60190 

630-653-4000 


Arbors North 

204A West Highland Avenue 


618-546-5232 

Dekalb 

Ben Gordon Center 

12 Health Services Drive 

Dekalb, IL 60115 

630-620-6616 

DuPage 

Serenity House, Inc. 

891 South Route 53 

Addison, IL 60101 

630-620-6616 

DuPage 

DuPage County Health Department 

Women’s Program 

245 South Gary Avenue, Suite 202 

Bloomingdale, IL 60108 

630-231-7440 

DuPage 


799 Roosevelt Road 

Building 6, Suite 312 

Glen Ellyn, IL 60137 

630-942-9720 

DuPage 

Breaking Free 

800 West 5th Avenue, Suite 102B 

Naperville, IL 60563 

630-355-2585 

DuPage 

Cornell Interventions Woodridge 

2221 West 64th Street, 1st Fl., 

East Wing 

Woodridge, IL 60517 

630-968-6477 



Edgar 

Human Resources Center of Edgar and 


118 East Court Street, P.O. Box 1118 

Paris, IL 61944 

217-465-4118 

Effingham 

Heartland Human Services 

1200 North 4th Street, P.O. Box 1047 

Effingham, IL 62401 

217-347-7058 

Franklin 

Franklin-Williamson Human 

Services, Inc. / West Frankfort Office 


West Frankfort, IL 62896 

618-997-6483 

Gallatin 

Egyptian Public Health Department 

Box 181 Main Street 

Ridgeway, IL 62979 

618-272-4691 

Hancock 

Hancock County Mental Health Center 

607 Buchanan Street 

Carthage, IL 62321 

217-357-3176 

Henry 

The Good Shepard Foundation of Henry 

County, Inc. 

4166 South Oakwood Avenue 

Geneseo, IL 61254 

309-944-6205 

Iroquois 

Nexus Adolescent Chemical Health 

118 East Lincoln Avenue 

Onarga, IL 60955 

815-268-4274 

Jackson 


1080 East Park Street 


618-529-1151 

Edwards 

Southeastern Edwards Family 



Albion, IL 62806 

618-445-3559 

Fayette 


421 West Main 

Vandalia, IL 62471 

618-283-4229 

Fulton 


Systems. Inc. 

229 Martin Avenue 

Canton, IL 61520 

309-647-1881 

Grundy 

Grundy County Health Department 

1320 Union Street 

Morris, IL 60450 

815-941-3138 

Henderson 

Bridgeway, Inc. 

Access Road, Highway 164W 

Oquawka, IL 61469 

309-867-2626 

Henry 

Bridgeway A.D.A.P.T. Services 

137 East College 

Kewanee, IL 61443 

309-852-4331 

Iroquois 

Iroquois Mental Health Center 

323 West Mulberry Street 

P.O. Box 322 

Watseka, IL 60970 

815-432-5241 

Jackson 

Recovery and Addiction Program 

Southern Illinois Regional Social 

Services, Inc 



618-529-5353 



Jackson 

Southern Illinois Regional Social 

Services, Inc. (SIRSS, Inc) 



618-457-6703 

Jasper 

Southeastern/ Jasper Family 

Counselling Center 

902 West Jourdan 


618-783-8615 

Jefferson 


Services - Vantage Point (Residential) 

Route 37 North, P.O.Box 428, Unit C 

Mount Vernon, IL 62864 

618-242-5835 

Johnson 

Family Counseling Center, Inc. 

408 East Vine Street 

Vienna, IL 62995 

618-658-2611 

Kane 


751 Aurora Avenue 


630-801-0017 

Kane 

Gateway - Opportunity House 

469 North Lake Street 


630-859-1870 

Kane 

Renz Addiction Counselling Center 

309 Walnut Street 

St.Charles, IL 60174 

630-513-6886 

Kankakee 

Aunt Martha's Youth Service Center 



815-937-5413 

Jasper 

Jasper County Health Department 

106 East Edwards Street 


618-783-4154 

Jefferson 


Services - Vantage Point (Outpatient) 

Route 37 North, P.O.Box 428 

Mount Vernon, IL 62864 

618-242-1546 

Jersey 

Tri-County Counseling Center 

220 East County Road, P.O. Box 381 


618-498-9587 

Kane 

Breaking Free, Inc. 

120 Gale Street 


630-897-1003 

Kane 

Gateway - Community Counseling 

Center of the Fox Valley 

400 Mercy Lane Southeast 


630-966-7400 

Kane 

Latino Treatment Center 

54 South Grove Avenue 


847-695-9155 

Kankakee 

Provena 

St. Mary's Substance Abuse Program 

21 Heritage Drive, Suite 102 

Bourbonnais, IL 60914 

815-937-2081 

Kankakee 

Duane Dean Behavioral Health Center 



815-939-0125 



Kankakee 

Provena St. Mary’s Hospital 

500 West Court Street 


815-937-2400 

Kankakee 

Riverside Medical Center 


Manteno, IL 60950 

815-468-3241 

Knox 


2323 Windish Drive 

Galesburg, IL 61401 

309-344-2323 

La Salle 


Systems, Inc. 

727 Etna Road 

Ottawa, IL 61350 

815-434-4727 

Lake 


Vernon Program Office 


Buffalo Grove, IL 60089 

847-634-9360 

Lake 

Lake County Health Department 

Lake Villa Counseling Center 

121 East Grand Avenue 

Lake Villa, IL 60046 

847-356-0058 

Lake 


Greenhouse Program Office 

115 North Seymour 

Mundelein, IL 60060 

847-949-1020 

Kankakee 

Riverside Resolve Center 

Oakside Clinic 

1905 West Court Street 


815-936-7373 

Kendall 

Kendall County Health Department 

811 West John Street 

Yorkville, IL 60560 

630-553-9100 

La Salle 


Systems Inc. 

2960 Charters Street, P.O Box 1488 

Lasalle, IL 61301 

815-223-0160 

La Salle 


Systems, Inc. 

17 Northpoint Drive 

Northpoint Shopping Center 

Streator, IL 61364 

815-673-3388 

Lake 

Gateway Foundation, Inc. 

Lake Villa Women's Program 

25480 West Cedar Crest Lane 1087 

Building B 

Lake Villa, IL 60046 

847-356-8205 

Lake 


Ela Township Office 

1025 Old McHenry Road 

Lake Zurich, IL 60047 

847-540-0680 

Lake 

Nicasa Women's Services 

2031 Dugdale Road 

North Chicago, IL 60064 

847-785-8660 



Lake 


Round Lake Park Office 

423 East Washington 

Round Lake Park, IL 60073 

847-546-0080 

Lake 

Cornell Interventions Contact 

Adolescent Outpatient 

26991 Anderson Road 

Box 341,Central Office 

Wauconda, IL 60084 

847-526-0404 

Lake 


Addictions Treatment Center 




Lake 

Northern Illinois Council on Alcoholism 

and Substance Abuse 

1113 Greenwood Avenue 


847-244-4434 

Lee 

LSSI - Dixon 

1247 North Galena Avenue 

Dixon, IL 61021 

815-288-6655 

Lee 

LSSI - Nachusa Lutheran Home - 

Phoenix Unit 

1261 Illinois Rt. 38, Phoenix Unit, 

P.O. Box 100 

Nachusa, IL 61057 

815-284-7796 

Logan 

The Wells Center, Inc. (Satellite Office) 

626 North Chicago Street 

Lincoln, IL 62656 

217-320-0070 

Lake 


Women's Residential Services 

24647 North Milwaukee Avenue 

Vernon Hills, IL 60061 

847-377-7835 

Lake 




847-377-8180 

Lake 

Lake County Health Department Alcohol 

and Substance Abuse Program 



847-377-8205 

Lawrence 

Southeastern/Lawrence Family 


1501 Olive 


618-943-3451 

Lee 


325 Illinois Route 2 

Dixon, IL 61021 

815-284-6611 

Livingston 

Institute for Human Resources 

310 East Torrance, P.O. Box 768 

Pontiac, IL 61764 

815-844-6109 

Macon 

Heritage Behavioral Health Center, Inc. 

151 North Main Street, P.O. Box 710 


217-362-6262 



Macon 

Saint Mary’s Treatment Center 

1800 East Lakeshore Drive 


217-464-2500 

Madison 

Community Counseling Center of 

Northern Madison County 

2615 Edwards Street 


618-462-2331 

Madison 

Chestnut Health Systems, Inc. 

50 Northgate Industrial Drive 

Granite City, IL 62040 

618-877-4420 

Marion 


101 South Locust Street 

Centralia, IL 62801 

618-533-1391 

Mason 

Wells Center, Inc. 

220 West Main Street, Rear Entrance 

Havana, IL 62644 

217-248-6678 

McDonough 




309-836-2334 

McDonough 


Systems, Inc. 

301 East Jefferson Street 


309-833-2191 

McHenry 

Family Service and Community Mental 

Health Center for McHenry County 

4100 Veterans Parkway 


815-385-6400 

Macoupin 

Macoupin County Mental Health Center 

100 North Side Square 

Carlinville, IL 62626 

217-854-3166 

Madison 

Saint Anthony’s Health Center 

St Clair’s Hospital 

915 East 5th Street, P.O. Box 340 


618-463-5600 

Madison 

Chestnut Health Systems 

2148 Vadalabene Drive, P.O. Box 750 

Maryville, IL 62062 

618-288-3100 

Marion 


1325 C West Whitaker 

Salem, IL 62881 

618-548-2181 

Massac 

Massac County Mental Health and 

Famliy Counseling Center, Inc. 

216 West 5th Street, 

Metropolis, IL 62960 

618-524-9368 

McDonough 




309-837-4876 

McHenry 

The Advantage Group Foundation, Ltd. 

422 Tag Way 

Crystal Lake, IL 60014 

815-444-6400 

McLean 

Chestnut Health Systems – Adolescents 

Chemical Dependency Treatment 

1003 Martin Luther King Drive 


309-827-6026 



McLean 

Chestnut Health Systems – 

Adult Chemical Dependency Treatment 

702 West Chestnut Street East 


309-827-6026 

Mercer 

Mercer County Center on Addictions - 

R.I.C.C.A. 

1607 John Deere Rd, 

East Moline, IL 61244 

309-582-5848 

Montgomery 

Montgomery County Health Department 

11191 Illinois Route 185 

Hillsboro, IL 62049 


Morgan 

The Wells Center 

1300 Lincoln Avenue 

Jacksonville, IL 62650 

217-243-1871 

Ogle 



Rochelle, IL 61068 

815-562-3801 

Peoria 

Human Service Center 

Central Intake Crossroads 

3420 North Rochelle Lane 


309-671-8040 

Peoria 

Human Service Center Youth and 

Community Services 

1200 Hamilton Boulevard 


309-589-7980 

Peoria 

New Leaf Retreat for Women 


3500 West New Leaf Lane 


309-689-3078 

McLean 

Illinois Institute for Addiction Recovery at 

Bromenn 

Virginia At Franklin 

Normal, IL 61761 

309-827-4321 

Monroe 

Human Support Services 

Substance Abuse Alternatives 

988 North Illinois Rt. 3, P.O. Box 146 

Waterloo, IL 62298 

618-939-4444 

Montgomery 

Montgomery County Health Department 

317 West Union Avenue 

Litchfield, IL 62056 

217-324-3430 

Ogle 



Oregon, IL 61061 

815-732-3157 

Peoria 


3300 West New Leaf Lane, 3300 Bldg. 


309-692-6900 

Peoria 

Human Service Center Outpatient 

Substance Abuse Services 

228 Northeast Jefferson, P.O. Box 1346 


309-671-8000 

Peoria 

Illinois Institute for Addiction Recovery 

5409 North Knoxville Avenue 


309-691-1055 

Peoria 

White Oaks Knolls 

2101 Willow Knolls Drive 


309-689-3074 



Piatt 

Piatt County Mental Health Center 


Monticello, IL 61856 

217-762-5371 

Randolph 

Human Service Center of Southern 

Metro-East 

10257 State Route 3 

Red Bud, IL 62278 

618-282-6233 

Richland 

Southeastern Illinois Family Counseling 

Centers, Inc. 

504 Micah Drive, Drawer M 

Olney, IL 62450 

618-395-4306 

Rock Island 

Rock Island County 

Council on Addictions 

1607 John Deere Road 

East Moline, IL 61244 

309-792-0292 

Rock Island 

Robert Young Center - CMHC 

2200 3rd Avenue 


309-779-2094 

Rock Island 

Center for Alcohol and Drug Services, 

Inc./Illini Hospital 

801 Illini Drive 

Silvis, IL 61282 

309-792-4899 

Sangamon 

Gateway Foundation, Inc. 

Springfield Women's Program 

2200 Lake Victoria Drive 


217-529-9266 

Randolph 


Metro-East/Chester Office 

115 East Stacey Street 

Chester, IL 62233 

618-826-4547 

Randolph 


Metro-East 

104 Northtown Drive 

Sparta, IL 62286 

618-443-3045 

Rock Island 

Robert Young Center 

Arrowhead Ranch 

12200 104th Street 

Coal Valley, IL 61240 

309-799-7044 

Rock Island 

Center for Alcohol and Drug 

Services Inc., Rock Island Office 



309-788-4571 

Rock Island 

Robert Young Center for Community 

Mental Health 



309-779-3000 

Saline 


Department 

1412 U.S. Highway 45 North 

Eldorado, IL 62930 

618-273-3326 

Sangamon 

Triangle Center 



217-544-9858 



Shelby 


155 South Morgan Street 


217-774-5566 

St. Clair 

Gateway Foundation, Inc./Belleville 

7 North High Street 

Belleville, IL 62220 

618-234-9002 

St. Clair 

Cornell Interventions East St. Louis 

Methadone Clinic 

501 St. Louis Avenue 

East St. Louis, IL 62201 

618-271-4542 

Stephenson 

Sojourn House, Inc. 

565 North Turner Avenue 

Freeport, IL 61032 

815-232-5121 

Tazewell 

Tazwood Mental Health Center, Inc. 

3248 Vandever Avenue 

Pekin, IL 61554 

309-347-5522 

Union 

The Fellowship House - Res. Rehab./ 

Social Setting Detox. Program 



618-833-2194 

Vermilion 

New Directions Treatment Center 

153 North Vermilion Street 


217-442-9026 

Wabash 

Southeastern Illinois Counseling Center/ 

Wabash Family Counseling Center 


Mt. Carmel, IL 62863 

618-262-7473 

Shelby 

Shelby County Community Services, Inc. 

1810 West South 3 rd Street 


217-774-1400 

St. Clair 

Gateway Foundation Caseyville 

600 Lincoln, P.O. Box 630 

Caseyville, IL 62232 

618-345-3970 

St. Clair 

Center for Addictions Rehabilitation 

Treatment Services ( Center for Arts) 

4601 State Street 3 rd Fl. 

East St.Louis, IL 62205 

618-482-7373 

Tazewell 


100 North Main Street, Suite L 100 

East Peoria, IL 61611 

309-694-6462 

Union 

The Fellowship House 



618-833-4456 

Vermilion 

Alcohol/Chemical Evaluation Services, 

Dba A.C.E.S., Ltd. 



217-841-4616 

Vermilion 

Prairie Center Health Systems, Inc. 



217-477-4500 

Warren 


219 Euclid Street 

Monmouth, IL 61462 

309-734-9461 



Wayne 

Southeastern/Wayne Family Counseling 

Center 

407 North Basin 

Fairfield, IL 62837 

618-842-2125 

Whiteside 

LSSI - Sterling 

1901 1st Avenue 


815-626-7333 

Will 

Cornell Interventions Lifeworks 

1611 West Jefferson Street 


815-730-7521 

Will 

Stepping Stones, Inc. 

Short Term Residential Rehab. Adult 

1621 Theodore Street, 1st Floor, West 


815-744-4654 

Will 

Riverside Resolve Center 

25711 South Egyptian Trail 

Monee, IL 60449 

800-435-4635 

Winnebago 

P.H.A.S.E., Inc. 

516 Green Street 


815-966-1285 

Winnebago 

Rosecrance, Inc. - Monarch Outpatient 

1322 East State Street Suite 301 


815-490-0077 

Winnebago 

Rosecrance, Inc. 

Griffin-Williamson Campus 

1601 University Drive 


815-391-1000 

White 


Department 

1705 College Avenue 

Carmi, IL 62821 

618-382-7311 

Whiteside 


2611 Woodlawn Road 


815-625-0013 

Will 

Stepping Stones, Inc. 

1621 Theodore Street 


815-744-4647 

Will 

Will County Health Department 

501 Ella Avenue 


815-727-8521 

Williamson 

Franklin-Williamson Human Services 


Marion, IL 62959 

618-997-5336 

Winnebago 

Rosecrance River District Clinic 

810 East State Street, Suite 200 


815-391-0100 

Winnebago 

Rosecrance, Inc. 

Eastrock Outpatient Clinic 

5279 28th Avenue 


815-226-2720 

Woodford 


109 East Eureka Street 

Eureka, IL 61530 

309-467-3770 



Appendix 5 

Child and Family Connections Listing of Illinois 


Division of Community Health and Prevention 

Bureau of Early Intervention 

For further address information, see the DHS Web site: 

http://www.dhs.state.il.us/page.aspx?module=11&OfficeType=4&County 

County Agency 

Name /Number 

Adams ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Alexander Archway, Inc. 

618-529-3147 

888-340-6702 

Bond ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Boone Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Brown ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Bureau Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Calhoun ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Carroll Regional Office of Education 

for Carroll, Jo Daviess, and 

Stephenson Co. 

815-297-1041 

888-297-1041 

Cass ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

County Agency Name/Number 

Christian ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Clark Macon County Community 

Mental Health Board 

217-423-6199 

800-758-2705 

Clay ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Clinton Regional Office of Education 

#13 

618-532-4919 

800-661-0900 

Coles Macon County Community 


217-423-6199 

Cook 

North 

Suburban 

Cook 

Central 

Suburban 

Cook 

Southwest 

Chicago 

Cook 

Central/West 

Chicago 

800-758-2705 

Clearbrook Center 

847-385-5070 

800-585-1953 

Suburban Access, Inc. 

708-449-0625 

888-566-8228 

Easter Seals Society Metro 

Chicago 

773-233-1799 

888-266-7167 

Hektoen Institute for Medical 

Research, Cook County 

Children’s Hospital 

312-864-6575 

888-283-2329 



Champaign Crosspoint Human Services 

217-442-8097 

800-877-1152 

Cook 

North Chicago 

Cook 

South Suburban 

Child and Family 

Connections # 11 

312-942-7800 

800-289-7990 

Easter Seals Society of 

Metro Chicago 

708-429-8231 

800-597-7798 

Crawford ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Cumberland Macon County Community 


217-423-6199 

800-758-2705 

DeKalb Regional Office of Education 

for Carroll, Jo Daviess, and 


815-297-1041 

888-297-1041 

DeWitt Macon County Community 


217-423-6199 

800-758-2705 

Douglas Macon County Community 


217-423-6199 

800-758-2705 

DuPage PACT, Inc. 

630-493-0400 

800-637-7181 

Edgar Macon County Community 


217-423-6199 

800-758-2705 

Edwards Wabash and Ohio Valley 

Special Ed. Dist. 

618-378-2131 

800-463-2759 

Effingham ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Cook 

Southeast 

Chicago 

La Rabida Children’s Hospital 

773-324-7434 

800-862-1912 

Fayette ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Ford Crosspoint Human Services 

217-442-8097 

800-877-1152 

Franklin Regional Office of Education 

#13 

618-532-4919 

800-661-0900 

Fulton Education Service Region #26 

309-734-3336 

866-426-2160 

Gallatin Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

Greene ROE of Adams/Pike Counties 

217-222-9592 

888-222-9592 

Grundy Services of Will, Grundy and 

Kankakee Counties, Inc. 

815-730-2617 

888-329-0633 

Hamilton Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

Hancock Education Service Region #26 

309-734-3336 

866-426-2160 

Hardin Archway, Inc. 

618-529-3147 

888-340-6702 

Henderson Education Service Region #26 

309-734-3336 

866-426-2160 



Henry Peoria County Board for the 

Care and Treatment of 

Persons with a 

Developmental Disability c/o 

Allied Agencies 

309-672-6360 

888-482-4300 

Iroquois Crosspoint Human Services 

217-442-8097 

800-877-1152 

Jackson Archway, Inc. 

618-529-3147 

888-340-6702 

Jasper ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Jefferson Regional Office of Education 

#13 

618-532-4919 

800-661-0900 

Jersey ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Jo Daviess Regional Office of Education 

for Carroll, Jo Daviess and 


815-297-1041 

888-297-1041 

Johnson Archway, Inc. 

618-529-3147 

888-340-6702 

Kane DayOne Network 

630-493-0400 

888-282-0997 

Kankakee Services of Will, Grundy and 


815-730-2617 

888-329-0633 

Knox Education Service Region #26 

309-734-3336 

866-426-2160 

LaSalle Services of Will, Grundy and 


815-730-2617 

888-329-0633 

Lake Lake County Health 

Department 

847-360-7353 

888-539-3033 

Lawrence ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Lee Regional Office of Education 



815-297-1041 

888-297-1041 

Livingston Crosspoint Human Services 

217-442-8097 

800-877-1152 

Logan Sangamon County Health 

Department 

217-793-3990 

888-217-3505 

Macon Macon County Community 


217-423-6199 

800-758-2705 

Macoupin ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Madison Special Children, Inc. 

618-624-3309 

888-594-8364 



Kendall Day One Network 

630-493-0400 

888-282-0997 

Marshall Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Mason Sangamon County Health 

Department 

217-793-3990 

888-217-3505 

Massac Archway, Inc. 

618-529-3147 

888-340-6702 

McDonough Education Service Region 

#26 

309-734-3336 

866-426-2160 

McHenry Options and Advocacy for 

McHenry County 

815-477-4720 

888-376-8828 

McLean Crosspoint Human Services 

217-442-8097 

800-877-1152 

Menard Sangamon County Health 

Department 

217-793-3990 

888-217-3505 

Mercer Education Service Region 

#26 

309-734-3336 

866-426-2160 

Monroe Special Children, Inc. 

618-624-3309 

888-594-8364 

Montgomery Montgomery ARC 

Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Marion Regional Office of Education 

#13 

618-532-4919 

800-661-0900 

Moultrie Macon County Community 


217-423-6199 

800-758-2705 

Ogle Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Peoria Peoria County Board for the 

Care and Treatment of Persons 

with a Developmental Disability 

c/o Allied Agencies 

309-672-6360 

888-482-4300 

Perry Archway, Inc. 

618-529-3147 

888-340-6702 

Piatt Macon County Community 


217-423-6199 

800-758-2705 

Pike ROE of Adams/Pike Counties 

217-222-9592 

888-222-9592 

Pope Archway, Inc. 

618-529-3147 

888-340-6702 

Pulaski Archway, Inc. 

618-529-3147 

888-340-6702 

Putnam Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Randolph Special Children, Inc. 

618-624-3309 

888-594-8364 



Morgan ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Rock Island Education Service Region 

#26 

309-734-3336 

866-426-2160 

St. Clair Special Children, Inc. 

618-624-3309 

888-594-8364 

Saline Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

Sangamon Sangamon County Health 

Department 

217-793-3990 

888-217-3505 

Schuyler Education Service Region 

#26 

309-426-2160 

866-426-2160 

Scott ROE of Adams/Pike 

Counties 

217-222-9592 

888-222-9592 

Shelby Macon County Community 


217-423-6199 

800-758-2705 

Stark Peoria County Board for the 





309-672-6360 

888-482-4300 

Stephenson Regional Office of Education 



815-297-1041 

888-297-1041 

Richland ARC Community Support 

Systems 

217-347-5601 

888-459-5437 ext. 104 

Vermillion Crosspoint Human Services 

217-442-8097 

800-877-1152 

Wabash Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

Warren Education Service Region #26 

309-734-3336 

866-426-2160 

Washington Regional Office of Education 

#13 

618-532-4919 

800-661-0900 

Wayne Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

White Wabash and Ohio Valley 


618-378-2131 

800-463-2759 

Whiteside Regional Office of Education 



815-297-1041 

888-297-1041 

Will Services of Will, Grundy and 


815-730-2617 

888-329-0633 

Williamson Regional Office of Education 

#13 

618-532-4919 

800-661-0900 



Tazewell Peoria County Board for the 





309-672-6360 

888-482-4300 

Union Archway, Inc. 

618-529-3147 

888-340-6702 

Winnebago Access Services of Northern 

Illinois 

815-654-6170 

800-921-0094 

Woodford Peoria County Board for the 

Care and Treatment of Persons 

with a Developmental Disability 

c/o Allied Agencies 

309-672-6360 

888-482-4300 



Appendix 6 

Rehabilitation Referral Resources 


Referral Information 

Bureau of Disability Determination Services 800-225-3607- voice 

217-782-8283- voice 

800-362-7754 - TTY 

Bureau of Home Services 

(Respite and HIV Programs) 217-782-2722 - voice/TTY 

Centers for Independent Living 217-782-9689 - voice/TTY 

312-814-4037 - voice 

Community Resources - Transition and STEP 312-814-4920 - voice 

312-814-5000 - TTY 

Educational Services 217-524-4089 - voice/TTY 

Illinois School for the Deaf (ISD) 217-479-4200 - voice/TTY 

Illinois School for the Visually Impaired (ISVI) 217-479-4400 - voice/TTY 

Illinois Center for Rehabilitation 

and Education-Roosevelt (ICRE-R) 312-433-3120- voice/TTY 

Next Steps and Lekotec 312-814-4042 

Services for Persons who are Deaf or 217-785-9304 - voice 

Hard of Hearing 312-814-2939 - voice/TTY 





Appendix 7 

Division of Specialized Care For Children (DSCC) Referral Resources 

Regional Office Boundaries 





Appendix 7 

Champaign Regional Office 

Debra Taylor,PSM 

510 Devonshire, Suite A 

Champaign, IL 61820-7306 

(217) 333 6528 (Voice) 

(217) 244 8390 (TTY) 

(217) 244 4212 (FAX) 

(800) 779 0889 (Toll Free) 

DSCC Regional Offices and Contact Persons (PSM) 

Chicago South Regional Office 

Christine Griffith, PSM 

1309 S.Halsted, 3rd Fl, Suite 307 

M/C 418 

Chicago, IL 60607-5021 

(312) 433 4100 (Voice) 

(312) 433 4108 (TTY) 

(312) 433 4107 ( FAX) 

(800) 905 9995 (Toll Free) 

Marion Regional Office 

Janice Wieland, PSM 

State Regional Office Building 

2309 West Main Street, Suite # 119 

Marion, IL 62959-1195 

(618) 997 4396 (Voice) 

(618) 993 2481 (TTY) 

(618) 993 8929 (FAX) 

(800) 451 0464 (Toll Free) 

Olney Regional Office 

Sherry Brauer, PSM 

1102A South West Street 

P.O Box 159 

Olney, IL 62450-0150 

(618) 395 8461 (Voice) 

(618) 392 3869 (TTY) 

(618) 395 2902 (FAX) 

(888) 841 3232 (Toll Free) 

Chicago North Regional Office 

Sharla Luken, PSM 

722 W. Maxwell, 3rd Fl, Suite 350 

M/C 418 

Chicago, IL 60617-5017 

(312) 433 4114 (Voice) 

(312) 433 4122 (TTY) 

(312) 433 4121 (FAX) 

(800) 425 1068 (Toll Free) 

DuPage Regional Office 

Christine Lomax, PSM 

8205 South Cass Avenue, Suite #110 

Darien, IL 60561-5319 

(630) 964 9887 (Voice) 

(630) 964 9603 (TTY) 

(630) 964 7640 (FAX) 

(800) 455 2639 (Toll Free) 

North Cook County 

Regional Office 

August Nall, PSM 

8609 W. Bryn Mawr, Suite 202 

Chicago, IL 60631-3524 

(773) 444 0043 (Voice) 

(773) 444 0178 (TTY) 

(773) 444 0178 (FAX) 

(800) 924 0623 (Toll Free) 

Peoria Regional Office 

Kristine Simmons, PSM 


5415 North University Avenue 

Room # 106 

Peoria, IL 61614-4779 

(309) 693 5250 (Voice) 

(309) 693 5345 (TTY) 

(309) 693 5306 (FAX) 

(800) 382 8569 (Toll Free) 



Rockford Regional Office 

Vickie Lund, PSM 



Room # 106 

Rockford, IL 61103-1209 

(815) 987 7571 (Voice) 

(815) 987 7995 (TTY) 

(815) 987 7891 (FAX) 

(800) 651 9319 (Toll Free) 

St Clair Regional Office 

Jack Schurk, PSM 

1734 Corporate Crossing, Suite 1 

O’Fallon, IL 62269-3734 

(618) 624 0508 (Voice) 

(618) 624 0544 (TTY) 

(618) 624 0538 (FAX) 

(800) 842 7204 (Toll Free) 

Springfield Regional Office 

Deb Anderson, PSM 

Quantum Centre 

421 South Grand West 

2 nd Floor 

Springfield, IL 62704-3769 

(217) 524 2000(Voice) 

(217) 524 2011 (TTY) 

(217) 524 2020 (FAX) 

(800) 946 8468 (Toll Free) 

Rock Island Regional Office 

Jill Gehbauer, PSM 

Rock Valley Office Park 

4711 – 44th Street, Suite # 1 

Rock Island, IL 61201-7169 

(309) 788 4300 (Voice) 

(309) 788 6443 (TTY) 

(309) 788 7780 (FAX) 

(800) 651 9526 (Toll Free) 

South Cook County Regional Office 

Mary Ellen O’Brien, PSM 

6160 S. East Avenue, Suite 400 

Hodgins, IL 60525-4125 

(708) 482 0633 (Voice) 

(708) 482 1103 (TTY) 

(708) 482 2629 (FAX) 

(800) 425 5454 (Toll Free) 



Appendix 7 

DSCC County Listing - Regional Office Assigned 

Adams ……………. Springfield 

Livingston ………………Peoria 

Alexander ………… Marion 

Logan ………………….. Springfield 

Bond ……………… St.Clair 

Macon …………………. Champaign 

Boone …………….. Rockford 

Macoupin ……………… St.Clair 

Brown …………….. Springfield 

Marion ………………… St.Clair 

Bureau …………….. Rock Island 

Marshall ……………….. Olney 

Calhoun …………… St.Clair 

Mason …………………..Peoria 

Caroll ……………… Rockford 

Massac ………………….Peoria 

Cass ……………….. Springfield 

McDonough …………….Marion 

Champaign ………... Champaign 

McHenry ………………..Springfield 

Christian …………... Springfield 

McLean …………………Rockford 

Clark ………………. Olney 

Menard ………………….Champaign 

Cook ………………. See Page 2 and 3 Mercer …………………..Springfield 

Crawford …………… Olney 

Monroe ………………….St.Clair 

Cumberland ………... Olney 

Montgomery ……………St.Clair 

Dekalb ……………... Rockford 

Morgan ………………….Springfield 

DeWitt ……………...Springfield 

Moultrie …………………Champaign 

Douglas ……………. Champaign 

Ogle ……………………..Rockford 

DuPage …………….. DuPage 

Peoria ………………….. Peoria 

Edgar ………………. Olney 

Perry …………………….Marion 

Edwards ……………. Marion 

Piatt ……………………..Champaign 

Effingham …………... Olney 

Pike ……………………..Springifeld 

Fayette ……………… Olney 

Pope …………………….Marion 

Ford …..…………….. Champaign 

Pulaski ………………….Marion 

Franklin …………….. Marion 

Putnam ………………… Peoria 

Fulton ………………. Peoria 

Randolph ……………….St.Clair 

Gallatin ……………... Marion 

Richland ………………..Olney 

Greene ………………. Springfield 

Rock Island …………….Rock Island 

Grundy ……………… Peoria 

St.Clair ………………… St.Clair 

Hamilton ……………. Marion 

Saline ………………….. Marion 

Hancock …………….. Springfield 

Sangamon …………….. Springfield 

Hardin ………………. Marion 

Schuyler …………….…. Springfield 

Henderson ……………Rock Island 

Scott …………………… Springfield 

Henry ………………… Rock Island 

Shelby …………………..Olney 

Iroquis ……………….. Champaign 

Stark …………………… Peoria 

Jackson ……………….Marion 

Stephenson ………….... Rockford 

Jasper …………………Olney 

Tazewell ……………….. Peoria 

Jefferson ………………Marion 

Union ……………….….. Marion 

Jersey ………………….St.Clair 

Vermillon ………………. Champaign 

JoDaviess …………….. Rockford 

Wabash …………………Marion 

Johnson ………………. Marion 

Warren …………………. Rock Island 

Kane ……………………DuPage 

Washington ……………. St.Clair 

Kankakee ………………Champaign 

Wayne ………………….. Marion 

Kendall …………………Peoria 

White …………………… Marion 

Knox ……………………Rock Island 

Whiteside ………………. Rock Island 

Lake …………………… Rockford 

Will ……………………… DuPage 

LaSalle …………………Peoria 

Williamson ………….….. Marion 

Lawrence ………………Olney 

Winnebago ………….…..Rockford 

Lee ……………………..Rockford 

Woodford ………………..Peoria 



Appendix 7 

DSCC Cook County/City of Chicago 

ZIP REGIONAL OFFICE ZIP REGIONAL OFFICE 

60004 ….. North Cook Co. 





































60104 ….. Chicago North 





60126 ….. Chicago North(CC) 


































60406 ….. South Cook Co. 











60439 ….. South Cook Co.(CC) 





ZIP REGIONAL OFFICE 




60454 ….. South Cook Co. (CC) 

































ZIP REGIONAL OFFICE 




60608 ….. Chicago South 

























60633 ….. South Cook Co 












Appendix 8 

Procedure Codes Common to Healthy Kids Services 

Healthy Kids Program 

Procedure Description Recommended CPT Code 

Well-Child Visit 

EPSDT-Well Child Visit 99381-99385 (new patient) 

99391-99395 (established patient) 

(use appropriate CPT code for the 

medical service provided) 

Make Up Visit Use appropriate Well Child 

Visit Code or Evaluation and 

Management Code 

Developmental Assessment 

Early Screening Inventory 96110 

Developmental Profile II 96110 

Minneapolis Preschool Screening Instrument 96110 

Denver DST/Denver II 96110 

Project Memphis DST 96110 

Early Screening Profiles 96110 

Revised Developmental Screening Inventory 96110 

Revised Parent Developmental Questionnaire 96110 

Dial-R Developmental Assessment 96110 

Chicago Early Developmental Screening Inventory 96110 

Ages and Stages Questionnaires (ASQ) 96110 

Battelle Developmental Screener 96110 

Bayley Infant Neurodevelopment Screener 96110 

Brigance Early Preschool 96110 

Early Language Milestone Scales Screen 96110 

Infant-Toddler Symptom Checklist 96110 

Parent's Evaluation of Developmental Status (PEDS) 96110 

Parent’s Evaluation of Developmental Status- 

Developmental Milestones (PEDS:DM) 96110 

Parents’ Observation of Infants and Toddlers (POINT) 96110 

Temperament and Atypical Behavior Scale Screener 96110 

McCarthy Screening Test 96111 

Modified Checklist for Autism in Toddlers (M-CHAT) 96111 

Battelle Developmental Inventory 96111 

Bayley Scales of Infant Development 96111 

Vineland Social Maturity Scale 96111 

Vineland Adaptive Behavior Domain 96111 

Child Behavior Checklist 2-3 96111 

Piers-Harris Children's Self-Concept Scale 96111 

Otis-Lenon School Ability Test 96111 

Caregiver-Teacher Report Form, Ages 2-5 96111 

Child Development Inventory 96111 

Connor's Rating Scales 96111 

Early Coping Inventory 96111 



Erhardt Development Prehension Assessment 96111 

Hawaii Early Learning Profile 96111 

Infant-Toddler Developmental Assessment 96111 

Infant-Toddler Social and Emotional Assessment 96111 

Temperament and Atypical Behavior Scale 

Assessment Tool 96111 

Vineland Social-Emotional Early Childhood Scales 96111 

Hearing 

Screening test, pure tone, air only 92551 

Pure tone audiometry (threshold); air only 92552 

Audiometry, air and bone 92553 

Vision 

Visual function screening, automated or semi- 

99172 

automated, bilateral quantitative determination of visual 

acuity ocular alignment, color vision by 

pseudoisochromatic plates and field of vision (may 

include all or some screening of the determination(s) 

for contrast sensitivity, vision under glare) 

Screening test visual acuity quantitative, bilateral 99173 

Risk Assessment 

Risk Assessment, including but is not limited to e.g., 

GAPS, mental health, substance abuse, chronic 

conditions) 

Administration and interpretation of health risk 

assessment (Postpartum Depression Screening) 

Prenatal care, at risk assessment 

(Prenatal Depression Screening) 

99420 

99420 HD 

H1000 

Lead Screening 

Blood Lead Analysis 83655 

Epidemiology (used by health departments only) T1029 

Collection of venous blood (venipuncture) 36415 U1 

Collection of capillary blood specimen 36416 U1 

Blood Lead Testing System CLIA waived, Blood lead 

testing system (whole blood) 

83655 QW 



Appendix 8 

Healthy Kids Program 

Childhood Immunization CPT Codes 

Vaccination CPT Code Age Edits 

DTaP 90700 6 weeks - 6 years 

DTaP-Hib 90721 0 year - 71 months 

Dtap-HepB-IPV 90723 6 weeks - 6 years 

DtaP-IPV 90696 4 years - 6 years 

DPT 90701 6 weeks - 6 years 

Tetanus Toxoid 90703 2 months - 99 years 

Tdap 90715 10 years - 64 years 

Td (preservative free) 90714 7 years - 99 years 

Td 90718 7 years - 99 years 

IPV 90713 6 weeks - 17 years 

Varicella 90716 1 year - 99 years 

MMRV 90710 12 months - 12 years 

MMR 90707 1 year - 99 years 

Measles and Rubella 90708 1 year - 99 years 

Measles 90705 1 year - 99 years 

Mumps 90704 12 months - 99 years 

Rubella 90706 1 year - 99 years 

HIB 90645 (HbOC) 6 weeks - 71 months 

90646 (PRP-D) 6 weeks - 71 months 

90647 (PRP- 

OMP) 

6 weeks - 71 months 

90648 (PRP-T) 6 weeks - 71 months 

Comvax (Hib and Hep B) 90748 6 weeks - 71 months 

Pneumococcal conjugate vaccine, 

polyvalent 

90669 6 weeks to 4 years 

Pneumococcal Polysaccharide 

Vaccine, SQ or IM 

90732 * 2 years- 99 years 

Meningococcal Polysaccharide 

a Vaccine (MPSV4) 

90733 2 years - 10 years and 55 years and over 

Meningococcal Polysaccharide 

Conjugate Vaccine (MCV4) 

90734 11 years - 55 years 

Hepatitis A, adult dose 90632 19 years - 99 years 

Hepatitis A, pediatric/ adolescent 

dosage (2 dose schedule) 

90633 12 months - 18 years 

Hepatitis A, pediatric/ adolescent 

dosage (3 dose schedule) 

90634 12 months - 18 years 

Hepatitis A and Hepatitis B Vaccine 90636 18 years - 99 years 

(adult dosage) 

Influenza virus vaccine (TIV) 90655 6 months and older 




Influenza virus vaccine (LAIV) 90660 2 years - 49 years 

Rotavirus vaccine, live, oral 

(pentavalent) 

90680 6 weeks - 8 months 



Vaccination CPT Code Age Edits 

Rotavirus vaccine, human, 

attenuated, 2 dose schedule, live, 

for oral use 

90681 6 weeks – 32 weeks 

Human Papilloma Virus (HPV) 

types 6,11,16, 18 (3 dose schedule) 

90649 

9 years - 26 years 

Human Papilloma Virus (HPV) 

types 16 and 18, bivalent, 3 dose 

schedule, for intramuscular use 

90650 9 years – 26 years 

Hepatitis B Vaccine, dialysis or 

immunosuppressed patient dosage 

(3 dose schedule) 

90740 0 year - 99 years 

Hepatitis B Vaccine, adolescent 


90743 11 years to 15 years 

Heptitis B vaccines, pediatric/ 

adolescent (3 dose schedule) 

90744 0 year to 18 years 

Hepatitis B vaccine, adult dosage 90746 19 years - 99 years 

Hepatitis B vaccine, dialysis or 

immunosuppressed patient dosage 


90747 0 year - 99 years 

Hep B - Hib 90748 6 weeks - 71 months 

* Recommended in (1) immunocompetent persons age 2 years or greater who have 

various serious chronic diseases such as Chronic Pulmonary Disease, Congestive 

Heart Failure, Cardiomyopathy, Diabetes Mellitus, Chronic Liver 

Disease, Functional or Anatomic Asplenia and (2) immunocompromised persons age 2 

years or greater including those with HIV infection, Leukemia, Lymphoma, Hodgkin’s 

Disease, Multiple Myeloma, Generalized Malignancy, Chronic Renal Failure or 

Nephrotic Syndrome, and those who are receiving immunosuppressive chemotherapy 

(including corticosteroids) and those who have received an organ or bone marrow 

transplant.

Handbook for Healthy Kids Services Chapter HK-200 ... - HFS

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